Dr. Joe Casillas, an obstetrician in Southern California, routinely prescribes birth control for his patients. Though he's a practicing Catholic, he doesn't follow his church's stern warning that contraception is a sin. He believes women should have access.
Yet Casillas was dismayed when the Obama administration recently ruled that religious institutions had to follow the same rules as other employers and offer free contraception as part of health insurance coverage. The idea that the government would force Catholic hospitals to subsidize birth control - or, to avoid the mandate, drop health insurance for their employees - appalled him.
Now Casillas, a registered Democrat who voted for Obama in 2008, says he is not at all sure he can back the president for a second term. "It's given me pause," he said.
Similar shockwaves are reverberating across the country, as Obama's refusal to exempt religious employers from this provision of his health-care law has deeply angered many Catholics - who will make up a crucial, and unpredictable, chunk of the electorate in the November presidential election. About one in four U.S. voters is Catholic and as a group they have swung back and forth between Democrats and Republicans.
In recent days, the administration has said it is willing to work with religious institutions to find ways to cover contraception without violating principles of faith. But no concrete plans for compromise have emerged.
The protest has been led by the U.S. Conference of Catholic Bishops, which encouraged parish priests from coast to coast to read aloud fiery letters denouncing the federal policy during Mass. "It is hard not to see this new mandate as a direct attack on Catholic consciences and the freedom of our Catholic institutions," Los Angeles Archbishop Jose H. Gomez wrote in one such letter of protest.
The bishops also urged the faithful to bombard Congress and the White House with complaints. By Tuesday, more than 25,000 people had signed an online petition demanding that the rule be overturned.
FAIRNESS FOR WOMEN
The administration cast the decision as a matter of equity for women. The new federal health care law requires most insurance plans to cover preventive services, such as blood pressure checks and childhood immunizations, without a deductible or co-pay. An outside board of scientists and doctors recommended last summer that contraception be included as a preventive service and the administration agreed.
The mandate does not apply to insurance plans offered by churches and schools that serve and employ primarily people of one faith. Nor does it require any individual physician or pharmacist to provide a service he considers immoral.
But insurance offered by church-affiliated institutions that deal with the public at large, such as hospitals and universities, must cover contraception. The mandate takes effect for most employers August 1; religious employers can apply for a one-year extension.
Jon O'Brien, president of Catholics for Choice, a group that supports access to contraception, said he's heard from hundreds of women employed by Catholic institutions who welcome the new policy - and express anger at the bishops, who they see lobbying to deny them a benefit provided to others under federal law.
"They think it would be a great injustice that they be treated differently from other workers," O'Brien said. "Why is it they should be discriminated against?" Yet many are reluctant to speak out publicly, he said, for fear of angering their employer.
A new poll released Tuesday by the Public Religion Research Institute, a non-partisan research group whose board members include a number of religious leaders who have supported progressive causes, found that a majority of Americans - including 58 percent of Catholics - support a requirement that health insurance plans provide free birth control. A slight majority of Catholic voters, 52 percent, said religiously affiliated colleges and hospitals should also have to provide that benefit.
Without insurance, contraception generally costs $15 to $80 a month, depending on the method and brand. A recent study by the Guttmacher Institute, which supports expanded access to contraception, found that even among women who are employed, one in four says she's found it tough to afford contraception. The study found 18 percent of women who are on the birth-control pill sometimes skip doses or entire months to save money.
"I believe this proposal strikes the appropriate balance between respecting religious freedom and increasing access to important preventive services," Kathleen Sebelius, the secretary of Health and Human Services, said in announcing the policy last month.
The administration also pointed out that 28 states already require insurance plans to cover contraception if they cover other prescription drugs. In most cases, however, religious institutions can get around that requirement through exemptions and loopholes.
The new mandate offers just one loophole: Any employer, including a religious institution, can continue to offer the same health benefits it currently provides, so long as the plan is frozen exactly as is. If the employer or insurer raises costs, tweaks deductibles or changes the benefits in any way - which happens very frequently in most plans - the new rules apply.
Many Catholics - including key Catholic supporters of Obama - said the president gravely miscalculated, on both the moral issue and the political implications.
"These are questions that go to the heart of who we are as a people and as a church," said Douglas Kmiec, a conservative legal scholar who broke from his fellow Republicans to campaign for Obama in 2008 as part of an influential group called Catholics for Obama. "There's no question this will cause complications for Obama."
Obama won the Catholic vote decisively in 2008, on the strength of strong support from Hispanic Catholics. But polls show that a sizeable number of Catholics had already begun to shift allegiances to the Republican Party before this decision. While Catholics as a group still lean left, the Democrats held an edge of just six percentage points among the group last year - down from 16 percentage points in 2008, according to polling by the Pew Research Center.
Political analysts say even before this decision, Obama faced a tough challenge holding on to support from white, working-class Catholics in battleground states such as Pennsylvania, Michigan and Ohio. It was votes from that bloc that helped propel Republican George W. Bush to victory in 2004.
Another crucial group for the president: Hispanic Catholics in swing states such as Nevada, New Mexico and Colorado. Polls show many Latino voters are already upset at Obama for deporting a record number of illegal immigrants during his presidency; for some, this could be the final blow.
"I don't know what to tell you except that everyone's still stunned," said Robert Aguirre, president of the Catholic Association of Latino Leaders, a nonprofit group of business owners and civic leaders.
Obama could take an especially big hit on the issue politically if the Republicans pick Florida Senator Marco Rubio as a vice presidential nominee, political analysts said. Rubio, who is Catholic, has filed a bill to overturn the contraception mandate and could keep the issue alive.
A POLITICAL MISCALCULATION?
Catholics who have worked closely with the White House on various issues said they believe the administration misjudged the response for several reasons.
Polls show that as many as 98 percent of Catholic women in the United States have used birth control, despite the church's teachings.
And Obama received important support from Catholics in his grueling health-care fight; though the bishops opposed his overhaul, other prominent voices in the church supported him on the grounds that extending coverage to more Americans furthered social justice.
So the administration may well have believed that opposition to expanded contraceptive coverage would be muted, said Sister Simone Campbell, executive director of Network, a national Catholic social-justice lobbying group. "You could say they miscalculated," she said.
Indeed, several groups that supported Obama's general health-care goals have issued biting statements opposing the new mandate. "The administration got focused on the substance and missed the higher-level issue of conscience," said Campbell.
For Casillas, the ob/gyn in southern California, that issue of conscience is paramount. It doesn't violate his conscience to prescribe birth control - but he knows other Catholics have a different take. "I want to preserve their ability to maintain their moral compass," he said.
Catholics who continue to back Obama despite their dismay at the contraception mandate say they'll urge voters to consider all of the president's policies, not just this one ruling.
That tactic worked in 2008, when Catholics for Obama put out radio ads and booklets arguing that Obama's policies on aiding the poor and ending the wars in Afghanistan and Iraq were in line with Catholic social justice teachings - and made him a moral choice for president, despite his support for legal abortion.
The president seemed to be laying the groundwork for a repeat of that campaign when he spoke at the National Prayer Breakfast last week. He told the crowd of religious leaders that many of his policies, including his call for the wealthy to pay more in taxes, sprang from Biblical teaching. "For me as a Christian," Obama said, the proposed tax hike "coincides with Jesus's teaching that 'for unto whom much is given, much shall be required.'"
It's unclear how well that tactic will play in this election, after the latest furor. "The Obama campaign went out of its way in 2008 to court Catholics," said Stephen Schneck, a political scientist at the Catholic University of America who has advised the president on outreach. "This could be messing all that up."