By J.D. KLEINKE

WASHINGTON — Oral contraceptives may be small, but they are proving to be tough pills for a vast number of Americans to swallow.

Last week, the Sunlight Foundation reported that the contraception provisions of President Obama’s health reform law garnered 147,000 comments from the public — more than on any other regulatory ruling, on any subject, in the history of the nation. Really.

The unprecedented flood of comments came from a wide range of organizations and individuals who support or oppose mandated contraception coverage as part of Obamacare.

Supporters, in general, want to extend coverage for this cornerstone of women’s health; oral contraceptives are used not just for birth control, but also for the treatment of pelvic pain, irregular periods, fibroid tumors, ovarian cysts, endometriosis, severe acne, mood disorders, and excessive menstrual bleeding that could lead to anemia. Opponents, in general, want to block this extension based on religious, moral or personal objections to women using pooled insurance resources to pay for pills that enable sex-for-fun — and that can be used, as it happens, for early termination of an unwanted pregnancy.

Such are the gray areas of medicine, the mechanics of health insurance, and the culture wars at the heart of Obamacare.

When President Obama set out to fix a broken health insurance system and find a pathway to coverage for all Americans, he could not help but open Pandora’s Pillbox — focusing and intensifying nearly every one of our culture wars. This has less to do with the actual details of Obamacare than with the hard realities of how the health insurance system invades, pervades, and connects us all — as almost anyone involved in prior health reform debates, or in trying to manage health care for an insured population, would attest.

As evidenced by those 147,000 comments, the Obama administration is simply confronting, en masse, what everyone in myriad private health insurance administrations has been facing for decades: our health care system is the dumping ground for all of our worst, unresolved arguments as a society. It is a long, messy list, and runs from the ovary to the grave: access to reproductive technology for the infertile, access to abortion for unwanted pregnancy, childhood vaccination, domestic violence, mental illness, personal responsibility for self-destructive behavior, generational economic conflict, the value of heroic medical treatment, the denial of death.

Name a subject that inflames people and drives them into warring camps of irreconcilable, passionately held beliefs, and the keepers of the U.S. health care system (and now the architects and implementers of Obamacare) get to deal with it. Extend our current health insurance system to everyone outside its walls — the essence of Obamacare — and you spark every remaining culture war: health care as an earned good versus human right, access to care by illegal immigrants, social justice and the cycle of poverty, compassion versus stigmatization of substance abuse, and pesky little issues like using the tax code for re-distribution of wealth and the role of government in our private lives.

Abortion jumps out of Pandora’s pillbox first because the country has been engaged in a civil war over it — and not always just a cold civil war — for half a century. But contraception? One of the best ways to reduce abortion rates?? 147,000 comments???

By contrast and for some odd reason, there has been almost no public discussion of Obamacare’s coverage of vasectomy, the single most effective form of birth control. Which leads one to believe that this particular debate is less about abortion — or even sex-for-fun, as enabled by vasectomy — than about something else that apparently belongs on the list of unresolved cultural arguments: female sexual autonomy.

Yes, it may seem odd or appalling that we are even having this discussion in the current century — until you take a quick glance at some of those 147,000 comments, posted by people nonetheless sufficiently modern to access the Internet. Perhaps I’ve been over-conditioned by decades of HBO and Showtime, but I’d assumed that sex-for-fun was like fluoride: it’s in the water, and people can’t really still be arguing about it, right? Apparently they are — and The Scarlet Letter is one of the most durable works of American literature for good reason.

In the current century, we can no longer run Hester Prynne out of town — but we can try to run her out of the insurance pool. This would be the core rationale for much of the opposition to the contraception rule, and shows a perfect misunderstanding of how our health insurance system works today and will work when extended under Obamacare.

The National Republican Congressional Committee sponsors a menacing-sounding website, “Living Under Obamacare,” that serves as an online bunker for potshots against health reform. A testimonial at the top of the site’s section dedicated to “Women Living Under Obamacare” is a perfect example of the public’s uninformed whining about Obamacare on its face, but is actually about health insurance in general.

“I had a hysterectomy, I have no need for maternity coverage, but I have to now pay for it. I have to pay not only my own premium but I have to subsidize everybody else.”

One little technical detail about this 49-year-old woman’s complaint: there is no way that whatever insurance premiums she or her employer paid in relevant accounting years covered the cost of her hysterectomy, combined with all the medical care leading up to it and the medications to follow. Her surgery was “subsidized” by tens of thousands of the same young healthy women in her insurance pool she now finds so burdensome — women who will be getting pregnant and having babies on her dime, along with all those Hester Prynnes who just wanna have fun.

This is why premiums will be going up for those same women, and most likely for all younger people under Obamacare — to subsidize the greater medical costs incurred by older people. This is Insurance Economics 101.

The inter-generational conflict elicited by trying to fix the broken health insurance market is corollary to the oddest cultural phenomenon of all in Pandora’s Pillbox: our exquisitely self-serving self-deception when it comes how health insurance works. It goes something like this: I’m paying for health insurance, so all my medical care should be covered, but to hell with any of your medical care I find morally objectionable. If I don’t approve of it, or just don’t feel like paying for it, then I shouldn’t have to. Sex-for-fun? For me, sure. Viagra good, but birth control pills bad — because I might not like what you do with them.

Luckily, most physicians in the U.S. do know how health insurance works. And as they did with managed care, they will find ways around the final version of the contraception rule, however contorted by the Obama administration to accommodate the birth control scolds. The Administration’s work-around right now is to designate separate new accounting entities for contraception coverage — because our health insurance system needs a little more complexity and paperwork.

This work-around may or may not ultimately appease opposition to this element of Obamacare by religious employers, but it will not matter in the trenches of medicine. Accounting entities deal in the black-and-whites of political accommodations and coverage rules; medicine deals in the gray areas of anxiety, need, fear, perception, deception, and what is or isn’t written down somewhere for submission as an insurance claim. Pelvic pain, irregular periods, fibroid tumors, ovarian cysts, endometriosis, severe acne, mood disorders, and excessive menstrual bleeding are real, and they all have diagnosis codes.

For the past two decades. managed care has been training prescribers to shadow box with the system on behalf of what their patients really need. At the height of health care’s hyper-administrative madness in the late 1990s, more than half of physicians surveyed said they would falsify documentation to enable their patients’ access to medical care they believed they needed but insurers would not pay for. In a related study, more than a quarter of the public surveyed said they approved of such deliberate deception. Those numbers cannot have gone anywhere but up, as insurance coverage has gone down.

As Obamacare extends the current health insurance system to cover the previously uninsurable, so too will physicians and patients extend their current ability to cope with administrative complexity and intrusive rules.

“Birth control” pills, like so many others, may be named and used for one medical purpose, but are mobilized for a multitude of medical reasons. The FDA approves them, patients want them, doctors prescribe them, and insurers (and Obamacare) will cover them, one way or another. Even if the birth control scolds were able to prevail on contraception coverage and block Obamacare from allowing women to have access to pills for reasons that do not meet with their moral approval, it would not matter. Physicians will medicalize those patients, document other reasons for the prescriptions, and patients will get access.

Once again, our doctors will serve as our last line of defense in the fight against medical tyranny — tyranny committed by the very people who, when they are not crusading against reproductive medicine in its many forms, like to accuse Obamacare of imposing its values on the rest of us.

Rush Limbaugh, who probably knows a thing or two about gaming the nation’s prescribing systems, may think of women who use birth control as “sluts.” No doubt the same misogyny is driving — consciously or not — a large percentage of the 147,000 organizations and people who took time out from their busy day to comment in opposition to the contraception mandate. Most doctors, by contrast, think of them simply as women who have health insurance and either want or need oral contraceptives.

As far as the rest of us should be concerned, yes, it is our money but their business – a courtesy we hope they show us when it is our turn to visit the doctor.

J.D. Kleinke is a pioneering health care information entrepreneur, medical economist, author, policy expert, and business strategist.