Contraceptive Coverage

STORIES FROM THE FRONT LINES:
Health care providers share real-world accounts on why women need full contraceptive coverage

Submit your story and headshot via e-mail to aswann@arhp.org.

Carole Joffe, PhD
I was checking into a hotel in Phoenix for a national conference on women’s health issues.  As I was completing my registration, a friend, a doctor, came over and greeted me.  He told me enthusiastically that he had just been to a session  whose topic was making oral contraception available over the counter for medically eligible women, and thus presumably cheaper and easier to obtain (a situation that has not yet come to pass). Suddenly the young woman checking me in, with whom I had probably not even made eye contact, excitedly broke into the conversation: ‘Oh, wow! When is this going to happen?’ She went on to tell us that she was in her early twenties and had three children. Even though she worked at the hotel, she could not afford to be on the pill, her preferred method of birth control. That incident made a deep impression on me.  The hotel clerk probably made too much to qualify for Medicaid but enough to be able to afford the pill on her own, especially given the expense of raising three children.

From Carole Joffe, Dispatches from the Abortion Wars, Beacon Press, 2010, p. 111.

Krishna K. Upadhya, MD, MPH
A few months ago, a 16 year-old young woman came to my office with her mother requesting contraception.  After a long discussion about her options, she settled on the contraceptive ring and left to fill her prescription at the pharmacy.  When I came back to my office the next morning, I had several messages from her mother and the pharmacy informing me that her insurance company would not cover the product and the cost was too high for them to afford.  When I tried to call the insurer directly to request an authorization, I was informed that I would have to submit a letter in writing to an out of state address before anything would be considered.  The one option that was covered was an injection. My patient had rejected this option at our initial visit, but she said she would reconsider and reschedule to receive it.

The patient did not return until months later.  In the meantime, she had continued to have sex and was not consistent about using condoms.  My patient is not unique.  Nationwide, nearly 70% of teens will have had sex by the time they are 19.  Barriers to contraception, financial or otherwise, do not change people’s sexual behavior.  These barriers do, however, increase their chance of pregnancy and are one reason why nearly half of all pregnancies in our country are unintended and why we lead the developed world in the rate of teen pregnancy.

A.Evan Eyler, MD, MPH

As a family physician and psychiatrist, I have seen the importance of reliable contraception in the lives of women, men, and their families. For over ten years, I practiced at an independent, non-profit health center in an economically depressed area, serving primarily adolescents, young adults, and their children. Many of the young women and men who received services at this practice were intelligent, motivated individuals who were struggling to make good lives for themselves and their families, despite very limited resources. Some became the first ones in their families to graduate from high school. Many achieved stable employment, and a few became nurses, teachers, and other professionals. One became a pediatrician. My conclusion from watching the life stories of these young adults unfold is that control of fertility is an essential part of the journey out of poverty, particularly for women. Although a young woman living in poverty who becomes a mother too soon or too often may occasionally manage to achieve economic stability and a life with good opportunities for her children, the odds are weighted heavily against her, and against her children.

Reliable contraception is an extremely good value as an investment in the future of this country, enabling young adults to avoid pregnancy long enough to enter gainful employment and stable family relationships without depending on public assistance. But the most effective methods are often beyond the financial means of the adolescents and young adults who need them most. It is both ironic and appalling that pregnancy care is often funded in full (as it should be) while the means to prevent pregnancy from occurring too early or too often are kept beyond reach. Over the last 30 years, I have had the pleasure of working with colleagues practicing a variety of religious faiths. I have met very few physicians and nurses, of any faith, who do not support full contraceptive availability and access.

Michael A. Thomas, MD
As a reproductive endocrinologist who conducts contraceptive research, I feel that I have a unique perspective in reproductive health issues.  However, seeing patients who are trying to get pregnant or those who are trying to prevent pregnancy may go against the views of some.  In my community, my infertility and contraceptive teams were asked to leave a hospital that we had practiced in for about 5 years because it was thought that we conflicted with the new religious based hospital system.  Though our practice of medicine covers infertility, menopause, hormonal disorders, and contraceptive management, it was thought that this did not fit their view of how women’s health should be practiced.  By acquiring two hospitals in the community, it forced tens of thousands of women to seek basic services outside their local communities and many had to leave the state.

Patricia A. Murphy, CNM, DrPH, FACNM
Planning an optimally timed healthy pregnancy is preventive care, pure and simple. There is more than ample evidence of the benefit of contraception in preventing adverse outcomes associated with unplanned or unwanted pregnancies. In the many years I have worked in women’s health care, in clinics and offices that provide free pregnancy testing as a service, I have known far too many women who found themselves pregnant at the wrong time or in a sub-optimal state of health or taking a medication that could compromise a pregnancy because they could not access effective contraceptives. When birth control methods cannot be purchased or afforded, as other preventive services can, women are denied an opportunity to be thoughtful and careful and responsible about their health and their lives.

Yukiko Giho, MSN, CRNP
I have seen so many women who can only choose a contraceptive method based on what she can possibly afford, if not giving up the idea of using a method totally. One of my patients works at a Catholic affiliated hospital and has a health insurance, but contraceptive services are not covered.  When she comes to our office, her choice of contraception is very limited because she can only choose from methods that fit her budget for paying out of pocket. Due to her health history, I recommended that she switch from using Depo-Provera, the injectable contraception. While she was interested in finding an alternative, she could not afford to pay for any of the other methods. Against my advice, she has chosen to stay on Depo-Provera.

She is still a fortunate person in the sense that she is still able to use any contraceptive method.  So many women just simply give up using a method when they lose insurance or their financial situation changes. I have seen too many women who come back to my office pregnant and tell me that they stopped the methods they were using.  Women need contraceptive coverage regardless of their employment status or employer’s belief.

Katharine Sheehan, MD
As part of our clinic’s Health Home grant through the Council of Community Clinics in San Diego, I went to talk with folks from Scripps Mercy Catholic Hospital and the University of California at San Diego Hospital emergency rooms about facilitating their referrals for urinary tract infections and miscarriage management to our health centers. The grant is aimed at trying to reduce inappropriate use of the emergency room as the patient’s medical home by facilitating referrals directly to the community clinics. At the end of the meeting, the head nurse of Scripps Mercy’s ER said to me: “Can you believe it? My hospital won’t pay for my contraception. I am not Catholic. My contraception is life-saving because I developed a dangerous heart condition at the end of my second pregnancy and was advised not to get pregnant again since my heart problems could come back. I wanted them to pay for permanent birth control such as a tubal ligation or transcervical sterilization but they refused. My Catholic hospital employs hundreds of women who should have the same birth control access as the women at UCSD four blocks away. Why should dogma trump my health care needs?

Anita Nelson, MD
Indigent men and women in California are very lucky. They have access to all forms of contraception free of cost. Based on this experience, we now have proof now that providing women contraception reduces unwanted pregnancy, and it reduces abortions. Ironically, many women with private insurance in California have far less comprehensive contraceptive coverage.  Indigent women in other states experience the tragedy of unwanted pregnancies, at least in part, because they cannot afford a method that would work well for them. This plan for free contraception for all women for the country will help women be more successful in planning and preparing for any pregnancies they desire.

But the problem of unwanted pregnancies has other causes too. I see women in my clinics sorely troubled by the misinformation they are given about how pills and IUDs work, to the point that they turn to less effective methods. I see women who are so frightened by reports of the possible risks of contraception they do not use it. What they don’t know – – what they need to know – – is about the very serious health risks posed by pregnancy. By raising issues of health risks of contraception out of the context of pregnancy risks and by spreading misinformation about the mechanisms of action of contraceptives (including Plan B), the health of women and their families is being sacrificed for political gain. I think this needs to stop now.

Physicians for Reproductive Choice and Health (PRCH)
Some religious institutions are objecting to new federal rules requiring their employees’ health insurance policies to cover contraception. Click here to read, PRCH physicians remember patients whose stories show the importance of affordable birth control for all women, no matter where they work. The patients’ names have been changed.

Pablo Rodriguez, MD
In addition to my job as an OBGYN serving a large Latina population,  I get the chance to talk to thousands of women every day through my call-in radio show “Nuestra Salud” on Latino Public Radio. For the last 3 weeks, we have been discussing the issue of contraceptive coverage by employers associated with religious institutions and the objections by the Catholic church to such coverage. The stories callers have shared have been wrenching. Even those who profess to be faithful to the teachings of the church have expressed their dismay at the opposition. We’ve heard of working women choosing less effective methods of contraception because they can’t afford the deductible or the co-pay for LARC methods. We’ve heard of women putting their health at risk because of losing their job or worse, having a job that does not pay enough to cover their weekly premiums. Most of them want to make the responsible decision to plan their pregnancies, but financial considerations make the decision for them. It is unconscionable for employers of any religion to refuse to cover what the Institute of Medicine has declared as essential preventive care. What will be next? Jehovah’s Witness’ refusing to cover blood transfusions? The principle would be the same.

Linda Dominguez, NP
I am certain that nearly every clinician in a practice that serves women of reproductive age has more than one story to tell about the potentially devastating and life threatening outcome that could happen when full contraceptive coverage is not available.

Last spring, a lovely 35 year old woman who is very happily married and is a highly successful professional woman presented to my practice. She had been diagnosed with metatastic carcinoma of the breast the year before. She survived her surgery and chemotherapy and had begun to have regular menstrual periods again.

Her options for contraception were limited. A non-medicated IUD was the most ideal choice for her and her husband to prevent a pregnancy until she “was out of the woods.” “I have to be cancer free.”

When we contacted her insurance plan to authorize the IUD, the stunning message came back as no birth control coverage at all because “this is a Christian plan.” One could ask, where was the Christian compassion for this loving couple who strived to get on the other side of this breast cancer and then hoped to start a family? Where was the concern for their relationship, this family of two who clung to each other through the many hours, days, weeks, and months of fear and illness. Where was the Christian ethic that supports the concept of a faithful, loving, married and yes a sexual relationship?

Jeffrey T. Jensen, MD, MPH
I have a lovely patient with debilitating pelvic pain due to endometriosis. She works as a school teacher, and prior to my treating her, she regularly missed work or suffered due to painful periods. Even though this woman is not sexually active, I started daily use of an oral contraceptive. Not only has this treatment been highly effective in managing her pain, it has also lowered her overall health care utilization and costs to her insurance company. However, until Oregon changed its law to mandate contraception coverage, she needed to pay out of pocket for her prescription since she worked as a teacher in a Catholic school. I wrote several letters asking for exemption explaining that the treatment is for a non-contraceptive indication, and that my patient is a virgin, -to no avail. This is one of the effects of ideology trumping medical decisions; many important treatments of gynecologic problems like endometriosis and heavy menstrual bleeding are also not covered as the contraceptive effect cannot be separated from the therapeutic effect.

Contrary to the media hysteria, President Obama is not forcing the Pope to use a contraceptive method. Nor will the new insurance regulation mandating coverage for contraceptives force priests, nuns, or for that matter any Catholics or non-Catholics opposed to contraception to use a birth control method. No laws also require the Catholic Church or any religious group to sponsor health insurance plans. While the Catholic health care system has a long and important tradition of direct medical care in the United States, only recently has this been expanded to include offering health insurance plans. When a religious group decides to enter the public market and become a provider of health insurance, it loses the right to pick and choose what is covered, and what is not covered.

Since many non-Catholics and Catholics not opposed to using contraception are covered by these plans, the new regulation simply provides equity for a high yield preventive health strategy that reduces the risk of unintended pregnancy, abortion, and lowers health care costs.  Every dollar spent on contraceptives saves five dollars on other health care related costs. I can’t help but conclude that opposing all aspects of health care reform has become a reflex among orthodox conservatives, most of whom use contraception themselves.  Why else would they oppose a policy that will actually reduce the number of unintended pregnancies and abortions, and also lower costs to public and private health care and reduce demand on social services?

Even well-to-do women can be placed at risk of unintended pregnancy when their coverage is inadequate. It simply makes sense to make contraceptive coverage the same as other prescription medications.

No one is forcing Catholics to run health insurance plans. And no one is interested in forcing anyone to use a contraceptive against their will. The ability to promote cost-effective public health strategies is a key advantage of a national health care policy. Creating uniform standards for health insurance plans should be a non-controversial step in the right direction.

Linda Byers, RN, CNS, WHNP-BC
I have been a Women’s Health Nurse Practitioner for 35 years. A few years ago, a very depressed, Spanish-speaking mother of three came to my clinic requesting contraception. In addition to providing a year’s worth of oral contraceptives, we offered a referral for depression care and a referral for English as a Second Language classes in her area. In one year, with the fear of pregnancy gone, she returned smiling, continuing her learning, and with a driver’s license that allowed some flexibility accomplishing her many necessary homemaker errands.

Voluntary contraception gives women a chance at a life. It gives children a mother who can care for them, not live in illness or constant fear.

Justin Diedrich, MD
As an OBGYN who takes care of people without insurance and without resources, I see the enormous difference contraceptive services make. In California we have a state-funded program (FamilyPACT) that provides birth control, pap smears, and STI treatment for free. The difference between people who know about FamilyPACT and those who do not is striking. When patients know their birth control is free they can focus on the rest of their family, they can focus on school instead of working a part time job, and they can focus on their future. The biggest difference we can make as advocates and as health practitioners is to see that the most vital of services is covered. Controlling one’s fertility is tantamount to fighting poverty, to empowering women, and to focusing on family values.

Kristy Chambers, CPA
As the executive director of a homeless healthcare clinic in Salt Lake City, Utah, I frequently see women requesting contraception to delay child birth until they are better prepared, both financially and emotionally, to support another life. With the economic decline, the clinic has seen an uptick in single mothers, families, and their children presenting as patients to our clinic. Families now comprise over 50% of Utah’s homeless population. Contraception, requested by our patients, is fundamental in breaking the cycle of intergenerational poverty that often exists when homelessness is extended due to insufficient resources to support the family unit.

Scott Spear, MD
As a physician practicing in community family planning clinics in Texas, I frequently see working women who do not have insurance coverage through their place of employment. These women often forego recommended testing for sexually transmitted infections or cervical cancer screening so they can have enough money to pay for their birth control pills. In some cases, they may be ideal candidates for long-acting reversible contraception, such as an IUD or implant, but they are living paycheck-to-paycheck and cannot afford the large initial investment cost required of an uninsured woman. In the long-run, the IUD makes considerable economic sense for the woman and her family, but the lack of coverage for the initial cost outlay prevents her from making this sensible and healthful decision. The rule enacted by the Department of Health and Human Services and upheld by the President last week to require insurance plans under the Affordable Care Act to cover contraception will be a terrific help for many women in Texas and across our nation who have previously been unable to receive these critical preventive health care resources.

Sandra Lovings, RN, NP

I work with an underserved population. Without free contraceptives, we will have more child neglect, abuse, and back alley abortions leading to increased emergency room care and increased morbidity and mortality for women and babies. We see thousands of women who need contraceptives every year, and at least 85-90% are Catholic. Religion doesn’t dictate decisions made by women or men. We have seen reduced abortions, child abuse, neglect, maternal morbidity and mortality, and neonatal morbidity and mortality with the use of birth control.

I support the president’s decision to provide free contraceptives to all women.

Nada Stotland, MD, MPH
As a physician specializing in psychiatry, and particularly in psychiatric aspects of women’s reproductive health, I know that full contraceptive coverage is essential for the health of America’s families.  It is the only way to minimize the incidence of abortion and to assure that babies are born only when they are wanted and can be cared for.  The leadership of the Catholic Church knows, but does not want to acknowledge, that Catholic women use contraception at the same rate as non-Catholic women—-in other words, even the members of the Church have long rejected the ban on contraception. No one is requiring anyone to use contraception, however only that women working for Catholic-based organizations have access to essential health care.

Linda Burdette, MPAS, PA-C
The female providers in my practice need help with contraception coverage. They are working very hard to become professional care-givers; students who want to become nurses, doctors, dental hygienists, and radiology techs. They are practical women who are trying to be responsible in their very busy lives. They are tired and would like to control their fertility when they are working night shifts and studying when they should be asleep. They might be able to afford one brand of oral contraceptives, but they would prefer IUDs or contraceptive patches or rings; reliable protection which is forgettable. Being unable to put together $1,000 for an IUD or afford $70 every month for a contraceptive ring prevents use of these excellent forms of contraception. These women lead demanding lives and they just want to learn to care for others and prepare for professional careers so they can also care for themselves and their families.

Diana Taylor, RNP, PhD
I am a volunteer nurse practitioner in an urban West Coast city free clinic, located near a Catholic university. Although the university requires that students have health insurance, it does not cover contraception care and its campus Student Health Service does not actively provide referrals. Access to contraception and unintended pregnancy prevention is even more hindered by the University’s health coverage policy. Students are given an out-of-date list of community providers, none of whom provide women’s healthcare or are taking new patients. These restrictions create delays in getting the quality reproductive healthcare students need, which often ends in positive pregnancy tests and visits to my clinic. I’ve heard it all, from “I tried to get a refill of my contraception,” “I didn’t think I would get pregnant this soon,” to “We used a condom but it broke.” The most tragic part of this problem is for the young men and women who don’t make it to our clinic and have to make unintended pregnancy decisions without support, information, and help back into primary prevention.

Kathleen Hill-Besinque, PharmD, MSEd, FCSHP
I work in a pharmacy, teach in a university, and see the impact that the high cost of contraceptives has every day. The cost to purchase contraceptives and other preventive medications can be beyond the reach for many—especially those with limited income. I’ve seen so many young women leave the pharmacy empty-handed when she has no refills and can’t afford the out of pocket cost. These women often ask if I can give it to her “this once” because she doesn’t have the money for both her prescription and the provider visit this week/month. Contraceptives are not a luxury for many of these women, they are working or in school. When the co-pay- only for a generic birth control pill is $10-$25/month, it adds up. No other type of prescription comes with 13 annual co-pays- only birth control. Many students have lost the ability to purchase birth control at student health centers with discounted pricing in recent years. Students ask me questions like: “can I take the pills only a few months at a time to save money?” and “can I take my pill every other day?” Every year, I have about five college students with unplanned pregnancies that disrupt their education. Better access and no co-pays would have made a tremendous difference to these women.

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