What, you're too busy shopping the discount stores for affordable presents, figuring out what to serve at that Chanukah party or Christmas dinner and - oh yes, worrying about your rent, your mortgage, the grocery bills, your 401K and even whether you'll still have a job come January? Don't have time to dust for Daschle? 

Yes, it's inconvenient. Surely, no woman would have suggested trying to host community health care meetings between December 15 and 31, but come on! When's the last time the U.S. Secretary of Health and Human Services asked to drop by and find out what we think about fixing America's broken health care system?  

We have an incoming administration that says it actually wants to hear what all of us think about the problems with the current system and what would improve it. Moreover, our next President says he thinks we need to get started on health reform right away, in the middle of the economic crisis. 

"It's not something we can put off because we're in an emergency," President-elect Barack Obama said at his news conference Thursday. "It's part of the emergency." He cited increasing joblessness, and the loss of health coverage that accompanies layoffs, skyrocketing health premium costs and the rise in personal bankruptcy filings related to medical debt. "The runaway cost of health care is punishing families and businesses," he said.  

With that, Obama introduced former Senator Daschle as his nominee to head not only the Department of Health and Human Services, but also a special health reform office within the White House. Daschle is no stranger to the women's health community, as Planned Parenthood Federation of America President Cecile Richards quickly pointed out: "Former Sen. Daschle has a strong record of standing up for women's health and women's rights and supporting commonsense policies that improve health outcomes for women." 

So, let's invite our friends, neighbors and family over. Go to http://change.gov/page/s/hcdiscussion to sign up to lead one of these discussions at your house, and let Tom Daschle know where to find you. Perhaps he'll even arrive early enough to help put out the napkins and cookies.  

While he's sipping and munching, what do we want to tell him? Here are some suggestions from "A Woman's Vision of Quality Health Care for All" produced by Raising Women's Voices for the Health Care We Need, based on small-group discussions with women like you all across the country: 

• Health care coverage must be affordable. Women and our families need to be able to afford not only the premiums, but also those co-pays and deductibles. Don't forget that women still earn, on average, only 75 cents for every dollar that men earn, and we use the health system a lot more, in part because of our need for reproductive health care. So, for example, we may have prescription drug coverage for birth control, but the co-pay for filling the prescription can make it unaffordable.
• Health care coverage must be always available. One quarter of American women get our health coverage through a spouse's employer, meaning we are at risk of losing it through divorce. Others of us are unable to get coverage at all because of insurance company policies denying coverage for people with pre-existing conditions, such as breast cancer, ovarian cancer or even having had a c-section delivery! Still more of us work at low-wage jobs that don't offer health insurance.
• Health care systems must provide the acute, preventive, chronic and supportive health care services that women and our families need. Let's start with comprehensive reproductive health care - contraception, sexuality education, sterilizations, abortions and a full range of childbirth choices - but don't stop there. We also need services across women's lifespans, including support for family caregivers, who are overwhelmingly women. Don't forget mental health and dental services.
• Health care systems must actively work to achieve equity and eliminate disparities in health care provision. Women who are low-income, immigrants and women of color are at the highest risk for having no health insurance or being under-insured.
• The health care system must be user-friendly, easy to navigate and transparent. Who can decipher all those insurance company rules and requirements? Who can make sense of the bills we get, or which doctors are in the networks we are supposed to use? Women know these problems intimately, because we are the arrangers of health care for most families.
• We must attain the highest attainable standard of health for women, our families and our communities. Health coverage is an important first step, but it can't be the only one we take. We need to address environmental threats to our health care, lack of healthy food choices for some urban residents and lack of recreational opportunities. Prevention and a health environment can keep us healthy!

Need more ideas of what to say? Visit www.raisingwomensvoices.net.  Let us know if you host a health care conversation in your home. Send us a summary of what was said (to info@raisingwomensvoices.net). If Tom Daschle didn't show up at your house, we'll help make sure he finds out what happened. We'll even send you a thank you!

Editor's Note: The following is excerpted from written testimony submitted by Lois Uttley, director of the MergerWatch Project, to the President's Council on Bioethics, which is meeting Thursday and Friday of this week. Lois's testimony concerns the harmful implications of proposed Dept. of Health and Human Services regulations regarding provider conscience, and puts forward alternative regulations that would protect patients' conscience and access to care.

Recently, a great deal of public attention and public policy has been focused on protecting the religious and ethical beliefs of health providers. As your council discusses this issue, I urge you to consider another imperative - protecting the rights of patients to receive accurate medical information and needed treatment in a timely manner. In a pluralistic society such as we have in the United States, public policy must carefully balance the needs and rights of all affected parties.

Let's use an example to make this discussion very concrete:

A 19-year-old rape victim - let's call her Sally -- is brought to a hospital emergency department by the police. The physician who treats her numerous injuries - Let's call him Dr. Brown -- omits any mention of the potential to prevent pregnancy from the rape by using emergency contraception, because he does not approve of it for religious reasons. Many hours later, Sally leaves the hospital without being informed about emergency contraception, or offered the medication. A friend takes her back to the college dorm where they live and Sally, exhausted, falls asleep for 24 hours. Because emergency contraception is the most effective when taken shortly after unprotected intercourse, Sally's opportunity to prevent pregnancy has now been greatly diminished.

What has just happened? Is this proper medical care? What are Sally's rights? What are Dr. Brown's? And, how should they be properly balanced? 

The patient's rights

Let's start with Sally. After all, the patient is supposed to be the focus of what the health professions now refer to as "patient-centered care." According to the Institute of Medicine, "patient-centered care is defined as health care that establishes a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions respect patients' wants, needs and preferences and solicit patients' input on the education and support they need to make decisions and participate in their own care."

One of the central tenets of patients' rights and "patient-centered care" is the right to informed consent. For a patient to make an informed decision about medical treatment, he or she must have knowledge of all potential treatment options, and their risks and benefits. In this case, the rape victim has not been informed about an important potential treatment option - use of emergency contraception to prevent pregnancy. As it happens, Sally is one of the millions of American women of reproductive age who are not aware of EC. So, Sally has had no opportunity to consider this option or use her own moral, ethical or religious perspectives to decide whether she wishes to risk the chance of bearing the child of a rapist. Further, she has had no chance to discuss with her physician the potential medical complications of an unplanned pregnancy, in view of her existing medical conditions, which include diabetes.

How could this violation of patients' rights be corrected? The simplest method would be to require all hospital emergency department personnel, including Dr. Brown, to always offer EC to rape victims who are of reproductive age.

Physicians' rights and responsibilities

But now, let's focus on Dr. Brown. A fundamentalist Christian, he believes that emergency contraception is the same thing as abortion, even though medical and scientific experts say that is untrue and the FDA has stated unequivocally that emergency contraception prevents pregnancy and does not cause an abortion.

Dr. Brown argues that requiring him to give emergency contraception to Sally would violate his religious beliefs. "I shouldn't have to give up my religious freedom in order to be a doctor," he says.

Let's pause for a moment to consider whether personal beliefs that are unsupported by or unrelated to medical science should be considered valid reasons why a licensed medical professional should be permitted to refuse to provide needed medical care, especially in an emergency situation in a facility that serves the general public. How far should we allow Dr. Brown or one of his colleagues to go with such claims? If Dr. Brown also believes that AIDS is a just punishment from God for perverted behavior, should he be allowed to refuse to treat any patients with AIDS? What if one of his colleagues believes that under Islamic law, anyone who committed murder should be sentenced to death? Should he be permitted to refuse to treat suspected murderers who are brought to the emergency room for treatment of wounds suffered in the attack? Where would we draw the line between acceptable and unacceptable moral reasons for refusing to provide care?

In the interests of moving our analysis along, however, let's set that issue aside and see if there is a compromise we could arrive at that would permit Dr. Brown to refuse to give EC to Sally, while still ensuring that she gets the medication in a timely manner. What if we just require Dr. Brown to refer Sally to another physician or a nurse in the emergency department who could inform her about EC and provide her the medication if she wishes to use it?

That, too, is unacceptable, Dr. Brown says, because it requires him to cooperate in helping the patient receive treatment he finds morally objectionable. "I cannot be implicated in any way in helping her commit an immoral act," he states.

One could argue that Dr. Brown's professional responsibilities to his patient should obligate him to provide Sally with at least a referral in such a situation. But, under a proposed "Provider Conscience Regulation" issued by the U.S. Department of Health and Human Services (HHS) on August 26, 2008, no entity receiving federal funding (such as the hospital where Dr. Brown works) could require him to give Sally the medical information or referral she needs if he claims a religious objection. To attempt do so would be to "discriminate" against him, and could result in the loss of federal funding, according to the rule. Not a single other physician or nurse in the hospital could be required to step in and give Sally what she needs, if that health professional held the same views as Dr. Brown.

Moreover, HHS has proposed a very expansive definition of the term "assist in the performance of" to permit refusals for "participation in any activity with a reasonable connection to the objectionable procedure, including referrals, training and other arrangements for offending procedures." Arguably, this definition would permit a pharmacy technician to refuse to stock emergency contraception in the hospital pharmacy, or a hospital purchasing agent to refuse to order it. Again, we face the question of where we should draw the line between acceptable and unacceptable refusals. The proposed HHS rule would seem to draw no line at all, instead allowing medical professionals and hospital personnel to use personal moral or religious beliefs to exempt themselves from any medical obligations to their patients.

Let's consider another alternative - requiring the hospital to be responsible for ensuring that Sally's rights as a patient are protected.

Hospital responsibilities

Arguably, the hospital should already be responsible for ensuring that Sally's medical needs are met. In order to participate in the federal Medicare program, and to be reimbursed under the Medicaid program, hospitals must adhere to "Conditions of Participation." These conditions are meant to ensure that patients' rights are respected and they received medically appropriate care. For example, hospitals are required to:

• "Honor a patient's right to make informed decisions regarding his or her medical care."
• "Meet the emergency needs of patients in accordance with acceptable standards of practice."
• "Have pharmaceutical services that meet the needs of patients."

But since the Medicaid/Medicare Conditions of Participation has not yet been enforced to require the provision of EC to rape victims, a number of states have enacted so-called EC in the ER or Compassionate Care for Rape Victims laws. These statutes specifically require hospitals to offer emergency contraception to rape victims, or, at minimum, inform rape victims about the potential to use the medication to prevent pregnancy.

How should the hospital go about fulfilling these responsibilities for patients like Sally? Should administrators fire Dr. Brown and replace him with someone who will dispense EC to rape victims? No, that would not be the preferable way of dealing with this situation, because there are far less drastic options available.

Instead, the hospital could offer Dr. Brown a transfer out of the ER into another unit of the hospital where he would not be expected to dispense EC, and replace him in the ER with someone who has no objections to EC. Such an arrangement would be an example of a "reasonable accommodation" under Title VII of the Civil Rights Act of 1964, which requires employers to reasonably accommodate an employee's religious beliefs or practices, unless doing so places an "undue hardship" on the employer's business. This type of careful balancing of competing rights is a hallmark of American public policy.

But, Dr. Brown might argue that he is being discriminated against even by such a reasonable accommodation, because it removes him from the practice of emergency medicine, which he sees as his mission in life. The proposed HHS rule might give him ammunition to do so, because it lacks any attempt to balance his rights with the patients' rights and the obligation of the hospital to serve its patients.

HHS Secretary Michael Leavitt, in a press conference to release the department's proposed rule, went so far as to frame the issue this way: ""Freedom of conscience is not to be surrendered upon issuance of a medical degree." He told reporters, "This is about protecting the right of a physician to practice medicine according to his or her moral compass."

Is there another solution? How about requiring the hospital to have a routine protocol of offering EC to all rape victims, and designating someone on each shift who does not object to EC to step in, inform the patient about EC and offer it? This surely would be somewhat cumbersome, and would require careful management of hospital staffing schedules. It also would require that Dr. Brown and any other hospital emergency department personnel who have objections to dispensing EC disclose those objections up front, so that hospital administrators can make appropriate scheduling decisions.

Religious hospital claims to "conscience" rights

But what if the hospital as an institution operates under a religious doctrine that expresses grave reservations about the use of emergency contraception? Let's put Dr. Brown and Sally in the emergency department of St. Mary's Roman Catholic Hospital. Like other Catholic hospitals, it is governed by the Ethical and Religious Directives for Catholic Health Care Services (ERDs), which offer guidance about EC that has been interpreted in a variety of ways.  Some Catholic hospitals provide EC to all rape victims. Some administer a pregnancy test, even though such a test would only be able to detect a pregnancy that was established prior to the rape (and if the woman is already pregnant, she does not need EC). Some require the rape victim to undergo an ovulation test. If the test comes back positive, EC is denied because of the hypothetical possibility that there might be a fertilized egg in existence. Still other Catholic hospitals refuse to offer EC at all.

St. Mary's Hospital, as it happens, is one of the Catholic hospitals that refuse to allow any dispensing of EC. Moreover, the hospital does not permit staff to even discuss EC with patients like Sally, citing another two of the ERDs.

Under a new state law taking effect in six months, St. Mary's and all other hospitals in this state (including Catholic ones) will be required to offer EC to rape victims. Dr. Gray, a colleague of Dr. Brown's in the emergency department, is happy about the new law, because he believes it is his professional and ethical obligation to serve the patient's medical needs, and he wants to be able to offer EC to patients like Sally. He is upset about what he views as the hospital's violation of his rights to use his own ethical beliefs and his medical training in deciding how to treat patients. (The proposed HHS regulation, it should be noted, does not seem to protect physicians like Dr. Gray, who wish to provide medical treatment, not refuse it, but are stymied by institutional religious restrictions.)

St. Mary's, which opposed the new law, hopes to argue that since it considers emergency contraception to be an abortifacient, it cannot be compelled to obey the law. Administrators of St. Mary's plan to cite the proposed HHS rule which, in seeking to enforce compliance with a longstanding federal law allowing federally-funded hospitals to refuse to perform abortions or sterilizations, seems to leave the definition of abortion open to interpretation.

The regulation, as promulgated, dropped a definition of abortion that had appeared in an earlier draft that had attempted to conflate contraception with abortion by including anything that could interfere with a fertilized egg. But, as the Washington Post reported, supporters and critics alike agreed that the language remains broad enough to apply to contraceptives. HHS Secretary Leavitt, in response to reporters' questions about the proposed rule, acknowledged that there was no definition of abortion and that some medical providers may want to "press the definition" and make the case that some forms of contraception are tantamount to abortion, according to the Wall Street Journal.

Does this mean that state health officials who try to enforce the new state law at St. Mary's - in order to ensuring that all rape victims are offered emergency contraception -- might risk being found guilty of "discrimination" against St. Mary's? Could the state lose all of its federal health funding as a result? Is that really the outcome we should be seeking in federal policy?

If St. Mary's were to be successful in its claim, what would happen to rape victims who need emergency contraception? Should they be expected to go to drugstores to buy it, even though they have just suffered a traumatic attack, may have had their clothes torn and may have been robbed of their purses, their money and their car keys? What if the local pharmacy also objects to emergency contraception? The proposed HHS rule, which purports to be about protecting health providers from having to perform abortions and sterilizations, extends provider conscience protections to pharmacies (and also, it should be noted to a wide variety of other health care institutions, including nursing homes and dentists offices).

Should rape victims be expected to leave St. Mary's and go to a different hospital, again in a traumatized state? What if St. Mary's is the only local hospital?

Conclusions

To hear HHS Secretary Leavitt and his colleagues tell it, the department's regulatory might and funding power must be marshaled behind medical professionals in this country who, they contend, are at serious risk of retaliation, firing or being forced to surrender their medical licenses for exercising their religious consciences. The department's introduction to its proposed rule on provider conscience states, "There appears to be an attitude toward the health professions that health care professionals and institutions should be required to provide to assist in the provision of medicine or procedures to which they object, or else risk being subjected to discrimination." The Department's commentary, however, did not supply a single example of a health professional who actually had been discriminated against.

Secretary Leavitt claimed at his press conference releasing the proposed regulation that "there is nothing in this rule that would in any way change a patient's right to a legal procedure" and that "this regulation does not limit patient access to health care."

But, as the story of Sally, Dr. Brown and St. Mary's Hospital has demonstrated, that would not be the case. In fact, the proposed HHS rule has the potential to seriously undermine the already fragile balance between providers' rights and patients' rights in the American health care system. It would tip the scales far over in the direction of objecting health providers, and leave patients at risk of going without needed medical information and care. It would allow providers' personal moral beliefs to come before patients' rights and would take American health care in the opposite direction from "patient-centered care."

Recommendations

Clearly, the proposed HHS rule should be withdrawn. It is both unnecessary and overreaching in its broad interpretation of those existing statutes.

But I also recommend that your council consider ways in which public policy could more strongly protect patients' rights and access to care, without unduly burdening individual health practitioners who have moral objections to providing certain medical services. What would be some ways of doing this?

• Patients' right to informed consent must be paramount. Patients must be informed of all potential treatment options so that they are able to give fully informed consent, based on medical recommendations and the patient's own ethical or religious beliefs.
• Acute care hospitals and any other health facilities that are licensed to serve the general public and receive patients needing emergency care must be required to provide such care immediately. When time-sensitive emergency care is needed -- such as for rape, an ectopic pregnancy or a miscarriage - a hospital must be required to provide it immediately on site.
• The ability of non-objecting health practitioners to fulfill their duty to their patients must be safeguarded. Physicians and other caregivers must be guaranteed the right to discuss all treatment options with patients, regardless of whether those options are permitted at the hospital or other health facility, and must be able to assist patients in obtaining desired treatment at alternate facilities.
• When health institutions serving the general public have treatment restrictions based on religious or ethical principles, they should be expected to disclose those policies to patients and individual health providers
• For non-emergency care, referrals to alternate practitioners or facilities must be made if treatment is being refused.

Or, you can tell it with numbers, using the new report on uninsured Americans released Tuesday by the U.S. Census Bureau: the percentage of women in this country with employer-sponsored health insurance fell in 2007 for the eighth consecutive year, to just 58.7 percent.

However you approach it, the harsh reality for women and our families is that our nation's health care "system" is failing us. We women need to be listening carefully to what the two parties have to say about health care reform at their national conventions, because the well-being of our families for the next four years is at stake.

As we think about what we want our next President and Congress to do about health reform, let's use the new Census data to take a look in the rear-view mirror at the health policy failures we have experienced over the last eight years:

• As more and more women lost employer-sponsored health insurance, the numbers of uninsured women rose from 18 million in 1999 (12.9 percent) to more than 21 million in both 2006 and 2007 (roughly 14 percent).

• How did women cope? More and more of them turned to public health insurance. Last year, the proportion of women relying on all types of public insurance (Medicaid, Medicare and military insurance) was up to an eight-year high of 29.8 percent.

• Women of color faced disproportionately high rates of uninsurance. Hispanic women, for example, had an uninsurance rate of 28.9 percent, while 17.9 percent of Black women and 15.7 percent of Asian-American women had no health insurance. By comparison, the uninsured rate for white non-Hispanic women is 9.6 percent.

• Where you live was a major predictor of whether you have health insurance. In the South, 19 percent of people were uninsured, compared to 17.9 percent in the West, 11.4 percent in the Midwest and 12.3 in the Northeast.

But those numbers don't capture the desperation of women sitting at their kitchen tables across America trying to figure out how to pay for health care for their families, when premiums, deductibles and co-pays are growing more expensive, coverage is getting worse and family budgets are stretched by high gas and food prices. Ask individual women about the state of health care in the United States -- as we have been doing at Raising Women's Voices for the Health Care We Need -- and you'll get an earful:

• "Our health insurance coverage has gotten dramatically worse."
• "I went to refill my birth control and the co-pay was $50!"
• "The doctor told me that my insurance would not even provide suitable coverage for his dog."

One mother of two who lost her insurance coverage after her divorce told us she hasn't gone to a doctor or had regular check-ups for over two years. "It's rough, I'm paying for disability and life insurance, car insurance, malpractice insurance and home owner's insurance," she said. "To add another $400 to $700 a month to the mix would mean I wouldn't be able to put food on the table."

Another woman told us she became ill while she was a full-time graduate student and temporarily uninsured: "I was in the hospital for five or six days and got a $30,000 bill." Her story of medical debt is becoming, unfortunately, an all-too-common one.

Are there any successes we can point to from our collective experience with the American health system over the last eight years? Fortunately, yes.

While the Massachusetts health reform experiment has plenty of critics, and even its proponents acknowledge it is a work in progress, the new Census Bureau numbers show it has made a real difference. Massachusetts had the highest rate of insured residents in the nation - 92.1 percent in a combined average for 2006 and 2007 - well above the national average of 86 percent and far out in front of the barely 75 percent in President Bush's home state of Texas.

"While we've had some bumps in the road with health care reform, it's well worth the effort and the resources we're putting into it," Massachusetts Health Secretary Dr. JudyAnn Bigby told the Boston Globe. Her boss, Gov. Deval Patrick, took the stage in Denver Wednesday at a forum sponsored by the consumer health group Families USA to talk about the state's reform plan.

We see another success in state efforts to expand the number of children receiving health coverage under the State Children's Health Insurance (SCHIP) program. Several states managed to do so over the last few years, and those actions produced a bright spot in the Census numbers released Tuesday: the number of children under 18 without health insurance fell from 11.7 million in 2006 to 11 million last year.

But that gain has come over the vehement objections of the Bush administration, which has tried to rein in spending on SCHIP. "Can you imagine an administration that decided to draw the line on health coverage for our children?" an indignant Ohio Gov. Ted Strickland told the Families USA forum Wednesday. He called for "a partner in Washington we can work with."