Self-Insurance Complicates Deal on Birth Control The Obama administration thought it had found a way to ease mounting objections to a requirement in the new health care act that all employers - including religiously affiliated hospitals and universities - offer coverage for birth control to women free of charge. It would make the insurers cover the costs, rather than the organizations themselves. But the administration announced the compromise plan before it had figured out how to address one conspicuous point: Like most large employers, many religiously affiliated organizations choose to insure themselves rather than hire an outside company to assume the risk. Now, the organizations are trying to determine how to reconcile their objections to offering birth control on religious grounds with their role as insurers - or whether there can be any reconciliation at all. And the administration still cannot put the thorny issue to rest. "We're all kind of waiting and seeing," said Jim Liske, chief executive of the Prison Fellowship, a Christian charity that insures itself and objects to offering the morning-after pill to its employees. The administration has remained mostly silent on how self-insured institutions will be treated, other than to say that the details will be worked out in meetings with religious leaders in the days and weeks to come. "This policy will be developed collaboratively so that the ultimate outcome works for religious employers, their workers and the public," an administration official said Wednesday. But some expressed skepticism that any satisfactory solution could be reached. "That's quite a trick," said Richard M. Doerflinger, associate director of "pro-life activities" at the United States Conference of Catholic Bishops, which has been among the most vocal critics of the birth control mandate. "Putting the obligation on the insurer and not the employer doesn't help much if they are the same person," he said. The Obama administration announced in January that it would require most health insurance plans to cover contraceptives for women free of charge as part of putting the federal health care law in place. Although the rule allowed churches to opt out for religious reasons, it did not extend the exemption to religious-affiliated institutions like hospitals or universities. The compromise plan, presented last Friday, has been embraced by some Catholic groups but opposed by others. Nicholas P. Cafardi, dean emeritus and professor of law at Duquesne University, a Catholic institution, said that President Obama gave the bishops exactly what they asked for. "The only serious issue left is self-insurance," he said Wednesday on a conference call with reporters. But the Obama administration has said it wants to work with these organizations so they're not required to violate their conscience. I'm sure they mean that in good faith. Employers that self-insure provide health insurance directly to employees, paying the health care claims of their workers. Large employers often choose to self-insure because they can spread the risk across hundreds or thousands of workers. The option is often more economical and can allow an organization to tailor its plan to the specific needs of its employees. Many such employers contract with an insurance company to administer the plan. Nationwide, 60 percent of workers with health insurance were covered by a self-funded plan in 2011, according to the Kaiser Family Foundation's annual survey of employer health benefits. Among large employers, the number is even higher. Eighty-two percent of covered workers at companies of more than 200 employees had self-funded plans. Insurance industry experts and Catholic groups said they did not know how many religiously affiliated organizations self-insure, but they said the number was likely to mirror the national trend. Many of the organizations are large employers, including hospital systems and universities. Several religiously affiliated organizations already offer coverage for contraceptives to their workers, often to comply with state birth control mandates. Among these are Dignity Health, which was affiliated with the Catholic Church until this year, and Fordham University, which is run in the tradition of the Jesuit religious order. In a curious twist, several Catholic organizations have chosen to self-insure in recent years to avoid the requirements of the state mandates, said Michael Galligan-Stierle, president of the Association of Catholic Colleges and Universities. "There's been a promise to have a conversation, but we haven't heard about when it's going to be," he said. We're waiting for that. Now those who self-insure say they worry that they will find themselves caught between following the law and following their consciences. "It seems to me that they've given a pretty clear signal that we are going to have to do something different," said Mr. Liske, of the Prison Fellowship, which employs 200 workers, 110 of them women. The organization views the morning-after pill as a form of abortion, which it opposes. And although Mr. Liske said he was heartened that the administration said it would work with groups like his to reach a solution, "anything that would put us in a situation where we would be directly or indirectly funding abortions would not be acceptable to us." One interest group that is likely to keep a low profile in the public debate is the insurance companies. "They don't want to get in the middle of this firestorm," said Robert Laszewski, a health care industry consultant and former insurance executive. You can't please anybody. Who do you want to offend - women's health advocates or the Catholic Church? Reed Abelson and Laurie Goodstein contributed reporting.