I’m a pediatrician. My patients need access to birth control.
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 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 a 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 she’d 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 that 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 are 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 they are 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 who 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 that 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 the Indiana University School of Medicine.