This post is part of the Birth Control Blog Carnival put on by the National Women’s Law Center.
Yesterday I wrote about new Institute of Medicine recommendations regarding preventive health services for women that should be covered by all new health plans without requiring cost-sharing. One of the IOM’s recommendations was that all FDA-approved contraceptive methods be available free of charge to women with reproductive capacity, and this was the one that attracted the most opposition. According to the Guttmacher Institute, 99% of women who’ve had sexual intercourse have used contraception. But a tiny sliver of the public opposes contraception, so that becomes the focal point of reactions to the IOM recommendations.
Here’s what I don’t think most people would argue with: easily accessible, effective contraception, consistently used by women who want to avoid pregnancy, is good for public health. As the Guttmacher Institute explains in its testimony to the IOM, “Contraception helps women avoid unintended pregnancy and improve birthspacing, with substantial, positive consequences for infants, women, families and society.” They also provide details on the cost of contraception, which can be prohibitive for some women, and what research has found about how costs affect contraception decision:
Methods of contraception vary not only in their effectiveness, but also in their costs and the timing of those costs. Condoms are relatively inexpensive on an individual basis, but 50 cents or a dollar per use can add up to substantial amounts of money over a year, much less the 30 years that the typical woman spends trying to avoid pregnancy. Brand-name versions of the pill, patch or ring can cost upwards of $60 per month if paid for entirely out-of-pocket, although generic oral contraceptives can cost considerably less; these methods also require periodic visits to a health care provider, at additional cost. Long-acting or permanent methods, such as the IUD, implant or sterilization, are most effective and cost-effective, but all can entail hundreds of dollars in up-front costs.
For many women, including the 11 million women of reproductive age (15-44) with incomes below the federal poverty level in 2009, these can be daunting expenses. That can be true even for those women with insurance coverage: Average copayments in employer-sponsored insurance have increased considerably over the past decade, to $49 in 2010 for “nonpreferred” brand-name drugs, $28 for preferred drugs and $11 for generics, for plans with a three-tier formulary (the industry standard). With copayments so high, private insurance is in many cases today providing only a marginal discount from what a woman would pay out-of-pocket at a drug store without insurance. In fact, a 2010 study found that privately insured women using oral contraceptives whose plan covered prescription drugs paid half (53%) of the cost of the pills, amounting to $14 per pack, on average. The same study found that the out-of-pocket expenditures for a full year’s worth of pills amounted to 29% of the women’s annual out-of-pocket expenditures for all health services.
… Several studies indicate that costs play a key role in the contraceptive behavior of substantial numbers of U.S. women. A national survey from 2004 of women 18-44 who were using reversible contraception found that one-third of them would switch methods if they did not have to worry about cost; only four in 10 of those women were using a hormonal method or an IUD, and nearly half were relying on condoms. In fact, women citing cost concerns were twice as likely as other women to rely on condoms or less effective methods like withdrawal or periodic abstinence.
… There is evidence that the impact of cost-sharing would specifically apply to contraceptive services and supplies. A recent study looked at the impact of a 2002 change in benefits at Kaiser Permanente Northern California to eliminate cost-sharing for the most effective forms of contraception (IUDs, implants and injectables). It found sizable increases in use of these methods–by 137% for IUDs and 32% for injectables–and a resulting reduction in women’s likelihood of contraceptive failure.
Looking at this and other evidence, the IOM concluded that offering contraceptive services has a large potential impact on health and well-being. Now the Department of Health and Human Services has to decide, based on the IOM’s recommendations, which preventive health services for women it should require new insurance plans to cover without cost-sharing.
This is where there’s room for debate. The vast majority of us can agree that it’s good for women to be able to use contraception consistently when they’re not seeking to get pregnant, but we may not agree on whether insurers should be required to foot the entire bill. And in this case, contraception is the item on the IOM’s recommended list that is most clearly in insurers’ interests to cover. Items like domestic-violence screening and coverage of lactation support and breastfeeding-equipment rental may help reduce health costs in the long run (and are certainly good for overall population health), but there’s a good chance that any long-term savings in healthcare costs will accrue to a different insurer, not the one who paid for preventive services in the first place.
Helping women who want to avoid pregnancy avoid it pays off for insurers very quickly, though. This New England Journal of Medicine editorial compares costs to Medicaid, which in 2008 paid an estimated $257 per client on contraceptive care and an estimated $12,613 per birth (including prenatal care, delivery, post-partum, and first-year infant care). Insurers all negotiate different rates with providers, but if anything that probably means an even bigger gap between the relatively low cost of contraception and the very high cost of births.
HHS needs to consider a multiple factors in deciding which preventive services to require new health plans to cover with cost-sharing for women. Public health is important, but so are insurer costs, which will influence the affordability of health insurance. If insurers have to cover every service that benefits public health, coverage will be out of financial reach for many – and high rates of uninsurance aren’t good for public health, either. Plans that cover contraception are likely to face lower overall costs, though, so it shouldn’t be hard for HHS to see that requiring contraception coverage without cost-sharing will benefit public health without jeopardizing insurance affordability. Eliminating the cost barrier to contraception benefits everyone.