A woman’s right to use the contraceptive method of her choice is an integral part of women’s healthcare and equality. Despite this constitutional right, barriers to contraceptive access still exist, as reflected by the high rate of unintended pregnancy in the United States each year.1 I believe that the federal government and state governments, not to mention insurance companies, should not have the right or the power to decide which type of contraception, if any, a woman may use. This decision should be solely up to a woman and her healthcare provider (HCP).
Statement of the problem
As a women’s health nurse practitioner for almost 20 years, I have educated reproductive-aged women about a variety of birth control methods. Although many of my patients know a lot about these methods, others are inadequately informed and undecided about them. As their HCP—and therefore their mentor and advocate—I teach them about all of the contraceptives available and guide them in making the best choices for them.
Through comprehensive contraceptive counseling, women are empowered to make their own decisions about their reproductive lives, including whether and when to have children. Even if women are adequately informed, many of them still face a daunting obstacle to accessing birth control—a lack of health insurance coverage for the particular contraceptive they want to use. It is not unusual to hear a patient say, “My insurance won’t cover that pill” or “The co-pays are too high for certain types of pills in my plan.”
Some women try several types of oral contraceptives before finding one that suits them. It is discouraging when a patient complains that she received a letter from her insurance company stating that it will “no longer cover pill X; you are being dispensed pill Y instead.” But after the patient switches to pill Y, she starts to have side effects that she never experienced with pill X. Many brand-name hormonal contraceptive products are not covered under insurance plans or they require high co-pays. If a woman wants to use a given product, she may need to get prior authorization for it, and prove that she is unable to tolerate alternative products. For a woman who chooses a long-acting reversible contraceptive (LARC), her insurance may cover the product itself but not the services of the HCP who prescribes and places it. These barriers can create undue stress and increase the risk for an unplanned pregnancy.
Overcoming the barriers
To overcome these barriers, HCPs need to advocate for complete contraceptive access for their patients. One form of advocacy involves awareness of public health policy at both the national level and the state level. HCPs can also intervene on their patients’ behalf at a very local level—in their own practices.
On the national level*
The Affordable Care Act (ACA) has a contraceptive coverage requirement giving millions of women who otherwise could not afford to pay for contraceptives the ability to make their own healthcare decisions about the use of such products and to obtain these products for free or at reduced cost. Despite this contraception coverage requirement, many insurance providers, politicians, and religious organizations have opposed the policy, creating further obstacles for women to reach full contraceptive access.2
With the election and inauguration of Donald Trump and a continuing Republican majority in both the Senate and the House of Representatives, the status of the ACA was in greater jeopardy than ever. Trump’s very first act as President was to issue an Executive Order aiming to repeal and replace the ACA.3 But the Executive Order wasn’t sufficient to dismantle the law, and an attempt to repeal the ACA and replace it with the American Health Care Act failed. If the ACA had been repealed, more than 55 million women would have lost access to vital preventive care at no cost,4,5 including access to annual exams, birth control, cancer screening, and testing for sexually transmitted infections.5
Of interest, right after the 2016 presidential election, there was a surge in contraceptive consultation visits around the country because women were concerned about the new administration’s goal to repeal the ACA.6 Women rushed in to get LARC methods out of fear that their insurance would drop contraceptive coverage completely.
On the state level
Some states are making it easier for underinsured or uninsured women who cannot afford to pay for healthcare visits and contraceptives to access these services and products. In 2015, I worked at a local non-profit clinic in New York where almost 18,000 women made family planning-related visits that offered full gynecologic examinations, contraceptive education, and birth control products.7 During this same year, these services and products were covered by a diverse payor mix: At least 50% of the patients had state-funded insurance, 26% had commercial insurance, and 16% were eligible for free services, including contraception.7
An example of family planning advocacy in New York is proposed legislation to ensure that residents have access to affordable contraception. The Comprehensive Contraception Coverage Act (CCCA), an extension of the ACA, introduced by New York Attorney General Eric T. Scheiderman, would codify the requirement under the ACA that all health insurers provide cost-free contraceptive coverage as a part of their insurance policies.8,9 Under the proposal, insurance companies would have to provide cost-free coverage for at least one type of all FDA-approved contraceptives, including emergency contraception. The bill would also apply to voluntary sterilization procedures, extending coverage to both men and women, and would prohibit insurance companies from using medical management review restrictions to delay contraceptive coverage. In addition, the measure would allow patients to receive a 12-month supply of contraceptives at a time.8,9
In 2010, New York was among the top three states in the nation in terms of the rate of unintended pregnancy.10 Public health policies such as the CCCA, which would improve access to contraception, could help reduce unintended pregnancy and abortion and improve health outcomes. As of January 2017, the New York State Assembly voted to pass this critical piece of reproductive healthcare legislation ensuring access to affordable contraception.9 This situation in New York State exemplifies why we need to continue to lobby our legislators on behalf of our patients to ensure their constitutional right to acquire contraception and ultimately uphold and protect their reproductive freedom.
On the local level
Healthcare providers can use certain strategies on their own to try to reduce economic barriers for their patients. For some of my patients who have commercial insurance with high co-pays, I’ve asked pharmaceutical representatives who promote hormonal and non-hormonal contraceptive products to provide discounts and/or coupons to help reduce the cost burden. I also ask the representatives to provide product starter samples, if available, to help reduce the annual cost of contraception. However, these starter samples are of minimal use if a woman cannot afford to pay full price for the product itself once the samples are gone. I also continue to encourage pharmaceutical representatives to provide cost-containment measures for their products if possible—again, to improve contraceptive access for as many women as possible.
Conclusion
It is disheartening that, in our current times, women still have the ongoing fight for reproductive freedom and have a government that creates barriers to this fundamental right. I am proud to live and work in a state that acknowledges the importance of safeguarding women’s health. Creating full access to reproductive health services is a human right that should never have to be challenged or placed in jeopardy by politicians or laws.
Rewa N. Thompson is a women’s health nurse practitioner at Planned Parenthood of Nassau County, Hempstead, New York, and a Clinical Assistant Professor at Stony Brook University, School of Nursing, Stony Brook, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.
Disclaimer
The findings and conclusions in this article are those of the author and do not necessarily represent the views of Planned Parenthood Federation of America, Inc. The author is an employee of Planned Parenthood of Nassau County.
* Addendum: As this issue of the journal goes to press, we know that the House of Representatives has voted to repeal and replace the Affordable Care Act with the American Health Care Act. The measure now goes to the Senate.
References
- Center for Reproductive Rights. Contraceptive Access in the United States. n.d.
- Center for Reproductive Rights. The Contraception Controversy: A Comprehensive Reply. April 2012.
- National Law Review. Status of the Affordable Care Act Repeal Efforts. January 23, 2017.
- Center for American Progress. How Women Would Be Hurt by ACA Repeal and Defunding of Planned Parenthood. January 18, 2017. americanprogress.org/issues/ women/news/2017/01/18/296705/how-women-would-be-hurt-by-aca-repeal-and-defunding-of-planned-parenthood/
- Planned Parenthood. Why Americans Are So Angry About Threats to Repeal Obamacare. March 2, 2017.
- PBS News Hour. Trump’s Vow to Repeal Obamacare Spurs Women’s Rush to Get Birth Control. November 22, 2016.
- Planned Parenthood of Nassau County. 2015 Annual Report.
- Comprehensive Contraception Coverage Act (CCCA).
- Assembly to Pass Legislation Protecting Women’s Reproductive Health Rights and Access to Affordable Family Planning.
- Guttmacher Institute. Unintended Pregnancy in the United States. September 2016.