Tracey Wilkinson | Vox

Why my patients will suffer under Trump’s new birth control rule

2017-10-12T12:43:46-04:00

A woman holds birth control pills in Washington in 2001. | Tim Matsui/Getty Images

In 2012, the United Nations declared access to contraception a “basic human right.” Last Friday, the Trump administration made moves to decimate women’s access to birth control — thereby continuing his administration’s war against women.

Last week, the Trump administration announced the rollback of an Obama-era requirement that employers to provide women with insurance that covers birth control. Under the new rule, employers can exempt themselves from this requirement for “religious or moral” reasons. Any employer, regardless of the business, can now opt out of covering contraception. If you are a woman, whether you have to pay for birth control out of your own pocket will soon be dictated by the religious and moral opinions of your employer.

As a pediatrician, I see how access to contraception improves patients’ lives. I have many patients who rely on it to prevent pregnancy so that they can finish their education. Parents of my younger patients also rely on contraception to ensure their pregnancies are planned. Some patients need birth control to regulate heavy or irregular periods. Access to birth control has been proven over and over again to be good not only for women’s health but also for the health of their families. Planned pregnancies result in healthier pregnancies and higher educational and economic attainment for both parents. But I am now worried that some of them won’t be able to afford birth control without health insurance coverage.

I remember taking care of a patient who wanted to try to use the contraceptive patch because she was worried she couldn’t remember to take the Pill every day. When she went to the pharmacy, she learned it was not covered by her insurance without prior authorization proving she had failed another method. Even with coverage under the ACA, the requirement was only to provide coverage for a method in each category, often leaving it up to physicians to determine which was covered for which insurance company. There was no way my patient would be able to pay for it out of pocket — the patch costs up to $55 a month without insurance coverage.

It took my office weeks of back and forth with the insurance company to provide sufficient documentation for her — and this all happened in the post-ACA world of health care, an overall improvement in birth control coverage. These bureaucratic and financial barriers will multiply and, for some women, become insurmountable under the new rules.

Of the 61 million women ages 15 to 44, 62 percent of them are using a contraceptive method. The importance of the ACA contraceptive coverage mandate is highlighted in data showing how many women benefit from this coverage. In just two years between 2012 and 2014, the percentage of women accessing the birth control pill — the most common form of contraception — without any cost rose from 15 percent to 67 percent.

Similar gains were found in other forms of contraception as well. And the results of this contraceptive coverage have spoken for themselves. There have been declines in both unplanned pregnancy rates and teen pregnancy rates nationally. The unplanned pregnancy rate declined 18 percent between 2008 and 2011. Research shows that these declines can be completely attributed to use of contraception, not people having less sex.

The Trump administration has asserted that Obamacare’s birth control mandate encouraged “risky sexual behavior” in young women. But no study has shown that access to contraception causes significant change in sexual behaviors. In fact, the largest study examining same-day access to all forms of contraception showed that while there were no changes in sexual behavior, rates of unplanned pregnancy and abortion dropped substantially. These are outcomes that our government should be seeking. Instead, the Trump administration has signaled that the religious and moral views of employers are more important than women’s human rights.

This change has the potential to affect all women of childbearing ages. Nine out of 10 women use contraception at some point. In fact, more married women use contraception than unmarried women. And plenty of religious women use birth control: 89 percent of women who identify as Catholic and 90 percent of Protestants report using some form of contraception.

Although four states have taken action to safeguard against continued efforts at the federal level, this leaves a patchwork of access throughout the rest of the country. Your contraceptive method will be covered while you live in one state, but take a job or go to another state that doesn’t have these protections and you may have to change contraceptive methods or start paying out of pocket for the method you’re using. Women require access regardless of where they live or work.

As a doctor, the health of my patients matters most to me — and this is a perfect case where the interests of my patients, especially women, are getting sidelined by political forces. And people will suffer as a result.

This isn’t just about women’s health. We have a right to have sex.

The average age of onset of sexual activity for both men and women is 17 years old in the United States, and that age has not changed substantially since the 1940s. What has changed is the average age that women have their first child and marriage — meaning there are more years to protect against an unplanned pregnancy. It seems clear that regulations around contraception do not affect whether people choose to have sex. It only makes it more unsafe and, in particular, forces women to navigate unnecessary obstacles to engage in normal human activity.

Women use birth control primarily to plan their pregnancies, but birth control is also used as a medical treatment for irregular or heavy periods, and as a preventive therapy for women with medical conditions that make pregnancy unsafe. In fact, 14 percent of women report using contraceptives for reasons unrelated to pregnancy planning.

The administration reasons that the Obamacare mandate places undue religious and moral burden on employers. But the religious objections of a boss do not supersede the importance of basic rights for women. The new religious exemptions allow employers to treat their workers differently simply based on their gender. It’s worth noting that during the Hobby Lobby controversy, the same Catholic groups that supported pulling coverage for birth control often covered the costs of drugs for men suffering from erectile dysfunction. (The ACA, however, does not require coverage of drugs for ED.)

In our health care system, financial access is everything

Studies show that fewer women will use contraception — and rely on less effective options — when it costs more out of pocket. A national survey done before Obamacare found that a third of women using a less effective contraceptive method, such as the Pill, would switch to another more effective method if they didn’t have to worry about the cost. Women who don’t use contraception or don’t use it reliably account for 95 percent of the unplanned pregnancies in the US. And the costs of unplanned pregnancy add up — studies have also shown that spending money on contraception is ultimately more cost-effective. In fact, for every dollar spent on family planning through Medicaid, $6 is saved in ultimate taxpayer costs.

But without coverage, birth control quickly becomes expensive. The most effective forms of birth control, long-acting forms of reversible contraception such as intrauterine devices, can easily cost over $1,000 out of pocket and are used for between three to 12 years. Even the birth control pill’s monthly cost of $20 to $50 per month will be a burden for most women. With the rollback in coverage, many women will rely on methods that are cheaper or less effective, or choose to use nothing at all.

Under Obamacare’s rules, many young adults are covered under their parents’ insurance plans long into their 20s. But after the rollback, it’s possible that their access will be determined by choices made by their parents’ employers. This is out of my patients’ control. When a patient’s parent was employed as a janitor at a small religious institution, her access to contraception was jeopardized. Although neither my patient nor her family had a religious objection to using birth control, the employer insurance plan did not cover it. Employers’ religious beliefs have no place in these private decisions.

The administration asserts that the government “already engages in dozens of programs that subsidize contraception for the low-income women” who are most at risk for unintended pregnancy. But the problem of unplanned pregnancies is not limited to the poor.

Currently 45 percent of all pregnancies in the US are unplanned, and that number is closer to 85 percent when you look at teen pregnancies. All women need access to contraception regardless of their socioeconomic status or place of employment. Moreover, in a remarkable act of cynicism, many of the programs for low-income women that the administration cites are facing funding cuts under Trump, including Planned Parenthood, Medicaid, and the teen pregnancy prevention program.

This new rule reflects a disturbing trend in both the Trump administration and the current Congress to dismantle women’s rights. The contraception coverage rollback does nothing to advance health, and the claims put forward to defend it are not supported by evidence. It’s a cruel, purely ideological gesture that will hurt real women — and the men and children in their lives.

Tracey Wilkinson is an Assistant Professor of Pediatrics at Indiana University School of Medicine and a member of Physicians for Reproductive Health.

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Obamacare was supposed to make all birth control free. As a doctor, I see it’s not happening.

2016-09-06T12:09:44-04:00

All contraceptives are to be covered without a copay.

That was the promise of the Affordable Care Act when it passed in 2010. The specific provision regarding contraceptive coverage took effect in 2013.

Advocates and policymakers repeat this assertion all the time. But I know, as many practicing physicians do, that it is not as simple as that.

I currently work primarily with low-income patients — now at a clinic in Indianapolis, and previously at one in California. I am reminded every day how hard it is for my patients to obtain birth control. Too often, I have patients return or call my office telling me that their insurance didn’t cover the birth control I prescribed, that there was a copay they could not afford or some roadblock has appeared that effectively denied them the method of contraception we had discussed.

Sometimes I will get a call from a pharmacy asking to change the birth control I prescribed — and that’s if the pharmacy happens to get ahold of me during business hours. Sometimes I will get a fax requesting insurance-specific paperwork to be completed to justify why a method was chosen over another.

But most frequently, it isn’t until the patient returns to tell me what happens that I find out she wasn’t able to get her birth control. This means she never started to use it and has been at risk for an unplanned pregnancy for the days, weeks, and months that have passed since I last saw her.

Low-income patients face multiple obstacles filling birth control prescriptions

There is one patient I remember clearly who wanted to begin taking oral contraceptive pills. We discussed the different types of pills and how we would start with a low-dose estrogen pill given that this was her first time using contraception.

I saw her during a follow-up a month later and learned that she hadn’t received the prescription that I sent to the pharmacy. When I called the pharmacy to figure out what happened, the pharmacist explained that the insurance company formulary didn’t cover the specific contraception I had prescribed. The health plan did cover one with a slightly higher dose of estrogen, and the pharmacy had tried to contact our office to substitute the prescription but had been unsuccessful in reaching us.

Too often, I have patients telling me that their insurance didn’t cover the birth control I prescribed

These types of administrative barriers to patients obtaining contraception are not unique.

In 2015, the Kaiser Foundation released a report documenting this same issue in five states around the United States.After interviewing staff at 20 different insurance companies, they too found a wide variety of contraceptive coverages were in place — some with cost sharing and some without. They also noted the difficulty in obtaining this information for the report and the fact that it was not always easy to find, readily available, or even known by the insurance company employees. This highlights again how challenging this is for a consumer or clinician.

Is the law being broken here? Not exactly. It is true that Obamacare requires insurance companies to cover the 18 FDA-approved types of contraception. But this means that coverage must include one method, at a minimum, from every category of contraception.

For instance, let’s consider the combined oral contraceptive pills used by millions of women in the United States. There are three categories of oral contraceptives: progestin only, combined, and extended use.While there are slightly over 100 different types of oral contraceptive pills on the market, an insurance company only has to provide coverage for one of them in each category.

Good luck remembering which one each individual insurance company has committed to covering when you see a patient.

Even worse, insurance companies can change what drugs they cover without notice. The electronic medical record systems I use rarely pick up this information in real time when prescribing medication for patients. It’s also possible that a pharmacy may not stock the specific form of contraceptive pill, even if it is covered by the patient’s insurance.

How insurance plans can still deny birth control coverage under Obamacare

Then there’s something called “reasonable medical management,” which allows insurance companies to require patients to try a cheaper contraceptive before moving on to a more expensive one. For example, if a patient would like to use a contraceptive patch, an insurance company can require a prior authorization clarifying why an oral contraceptive isn’t acceptable to try first.

This became an issue with a patient of mine who wanted to start using birth control. She was an adolescent and an athlete with a busy schedule. After discussing various options, she decided to try the contraceptive patch. This method would give her the contraceptive coverage she needed and would only require remembering to change it once a week. Many weeks passed until I actually saw the fax from the pharmacy: The insurance plan had denied the contraceptive patch because a contraceptive pill hadn’t been tried first.

The insurance company was requesting documentation from me as to why this patient needed this particular method of birth control over other daily methods. When I finally got in touch with the patient, she explained that she didn’t want to call our office about what had happened because she was worried her mother would find out what had been prescribed.

In May 2015, new federal guidelines began to restrict the use of “reasonable medical management” to within a method category. In other words, they can restrict different contraceptive pills but can’t require that you try a contraceptive pill before you try a contraceptive patch. That should go into effect over the next year.

However, insurance companies can still require a “waiver” or “exception” process that will involve some sort of paperwork completed by physicians to document why a certain contraception has been chosen after seeing the patient. This required paperwork will be added to the already busy clinical practice and is often not known to be required until after the patient goes to the pharmacy for the prescription.

What’s more, the Kaiser report mentioned earliernoted that none of the insurance companies interviewed had a specific appeal process set up for denials of coverage pertaining to preventive services.Instead, consumers go through the generic appeal process the insurance company has in place, which can often take weeks.

All of these barriers are legal and have been documented by various advocacy organizations. It is also important to note that the ACA regulations on contraceptive coverage only apply to Medicaid expansion programs and private insurance. Traditional Medicaid members, those who qualified for Medicaid before the expansion, are not guaranteed the “all-inclusive” contraceptive coverage touted recently.

Most traditional Medicaid programs do provide some contraceptives without additional costs, but the formularies they use to define coverage of certain types of contraception can vary from state to state and can change frequently.

Less access to birth control means more unintended pregnancies

What is most frustrating about the current state of contraceptive coverage is that it’s hard to determine who, if anyone, benefits from this restricted access. Unplanned pregnancies are very expensive not only to society but also to insurance companies. The cost of paying for contraception for a year (or even 10 years) is significantly cheaper than paying for prenatal care and subsequent labor and delivery. The estimated costs of unplanned teenage pregnancies in the United States each year is $9.4 billion.

Evidence exists showing that removing barriers to contraceptive use is effective and leads to a sharp decline in unplanned pregnancy, birth, and abortion rates. Consider the Choice Project in St. Louisand the Colorado Family Planning Initiative, two large-scale programs focused on providing the most efficacious forms of contraception, long-acting reversible contraception (LARC) like IUDs and implants. Both of these programs worked on removing barriers to contraception access for those at greatest risk for unplanned pregnancy — low-income women and adolescents.

They simply gave patients contraceptive options (emphasizing efficacy) and assured them they would leave with the chosen contraceptive method that day, free of charge. They required no prescriptions or trip to the pharmacy. They demanded no copays. No appointment to come back for placement was necessary, and no prior authorization was demanded required for a device.

As a result of this new model in access, study subjects overwhelmingly chose more efficacious forms of contraception. Both programs showed astonishing results cutting rates of unplanned pregnancy, births, and abortion rates by double digits.

Results like these should be celebrated by everyone, regardless of where they are on the political spectrum, because they are good for patients and for society. Improved outcomes were not a result of a new form of contraception, a medical breakthrough, or a change in behavior. All that was necessary was the removal of barriers to contraception coverage. The ACA may have intended to do that in theory, but in practice it is falling short.

Tracey Wilkinson is an assistant professor of pediatrics at the Indiana University School of Medicine.