New rules requiring free access to prescription birth control for women with health insurance go into effect on Wednesday, but controversy lingers at some Catholic institutions struggling to balance the requirement with their opposition to contraception.
At Georgetown University, the nation's oldest Catholic university, students and administration officials are still wrestling with the requirement to cover contraceptives as part of larger effort to expand no-cost preventive care for women.
The requirement exempts churches and gives religious groups a one-year reprieve. Georgetown leaders, now preparing for returning students, have said they will not allow student health plans to include birth control this year.
Other religious groups are pushing back further by filing lawsuits or dropping health insurance coverage altogether.
President Barack Obama's 2010 health care overhaul also calls for more no-cost screenings, check-ups and other services starting in 2014. The services are aimed at holding down spiraling health care costs by catching illnesses early, curbing complications or preventing unwanted pregnancies.
Catholic Church officials, Republicans and other conservatives have blasted the inclusion of artificial birth control, which is against church doctrine. Opponents said the rule, as it stands, does not go far enough to allow an opt-out for religious-affiliated groups such as charities or schools.
Obama, a Democrat, has softened the rule to allow more time for a compromise with religious groups over how to implement it without trampling their beliefs, but also without denying contraception to those with different views.
For example, health insurers and not the organizations could cover the costs.
Women's health advocates and other supporters laud the new services. About 47 million women covered by health insurance will benefit, according to federal health officials.
"This law puts women and their doctors, not insurance companies or the government, in charge of health care decisions," U.S. Health Secretary Kathleen Sebelius said.
At Georgetown, which sits less than three miles from the White House, the on-going controversy over student access to birth control on campus flared up in recent months.
Melissa Thelemaque, a Georgetown Law School graduate, said she didn't realize that students in the university health plan were covered by a blanket restriction on prescription birth control when she arrived on campus years ago.
Although she grew up in a Catholic family, she does not practice the faith herself and quickly joined a group of law students seeking wider access to contraceptives.
"I was sort of surprised," Thelemaque, who graduated in 2006, said of the policy, which does allow coverage for faculty and staff.
Despite the August 1 deadline, the next year will be a bumpy one for the contraceptives provision.
More than 199,000 comments - a significant number given that most government regulations draw minimal public response - on both sides of the issue have been submitted to Sebelius, who must still issue the proposed compromise.
Officials are reviewing the comments, Department of Health and Human Services spokeswoman Erin Shields Britt said, adding that she could not say when the proposed amendment would be issued. Any movement ahead of the November 6 election could impact support for Obama, who is seeking re-election.
At the same time, religious groups have filed dozens of lawsuits accusing federal officials of violating religious freedom.
So far, the results have been mixed.
Last week, a federal judge temporarily blocked enforcement of the rule for a Catholic-owned Colorado business while in June, a Nebraska judge dismissed a lawsuit from seven states over the contraception mandate.
The Catholic Health Association, the nation's largest nonprofit health facilities provider, also called on the White House to exempt its providers.
The November 6 U.S. election could also help religious groups opposed to the effort if Republicans win the majority in Congress or the White House.
Although the Supreme Court upheld the health care law in June, Republican presidential candidate Mitt Romney, who is a Mormon, has vowed to undo it. The Republican-controlled U.S. House of Representatives has already voted to repeal the law.
Catholic Church leaders have come down hard on Georgetown, which unlike the Catholic University of America across town is not controlled by the bishops. Georgetown's president, John DeGioia, repeatedly urged tolerance as congressional testimony by then-law student Sandra Fluke and a later graduation day speech by Sebelius thrust the school onto the national stage.
"Part of Catholic identity is to be in union with the bishops," Cardinal Timothy Dolan told CBS earlier this year, adding that it is the government's "intrusion that bothers us. It's not the contraception."
Jane Belford, chancellor for the Archdiocese of Washington, told Reuters the church has not pressured Georgetown or other schools to take further action.
Georgetown's DeGioia declined to be interviewed for this story, but a spokeswoman for the university, Stacy Kerr, said in an email, "We believe the best route to resolve this is through the regulatory process at HHS and that is the path we are pursuing."
Not all Catholics are opposed to birth control, and many people who submitted comments cited religious beliefs as a reason to be inclusive in allowing contraceptive coverage, especially for those of other faiths.
Polls from the nonpartisan Kaiser Family Foundation have also shown support for the policy, including among Catholics.
"Most of us in the pews are actually using contraception," said Jon O'Brien, president of Catholics for Choice, an advocacy group that backs women's reproductive rights.
The issue is likely to linger at Georgetown as students return to campus later this month.
Nearly 800 students signed an open letter to DeGioia urging the school to comply on August 1. More than 100 others signed an open letter against implementing the rule.
"He's in a complicated political situation," said one Georgetown law professor who asked not to be named, fearing possible university retaliation. "There is a dance that has to be done with the church and the students."
Georgetown Law Students for Reproductive Justice, the latest group to fight the contraceptives ban, plans on educating incoming students and "advocating our best to ensure that Georgetown students get access to contraception coverage at no-cost and with the greatest possible ease," its president, Kelly Percival, said.
Some other students on campus said those who decide to attend the Catholic school should not be surprised that birth control is not covered.
For Rachel Brill, who helped launch the law students' push over contraceptives in 2001, widening access is about equality. Unlike some other Catholic groups, Georgetown openly promotes religious diversity.
"What they're doing is imposing Catholic teaching on people who are not at all Catholic," said Brill, who is Jewish and now works as a labor lawyer in California.
"If you're going to actually have a diverse university, you have to be able to accommodate everyone, not just the people who agree with you," she said.