It is 2020. The American Health Care Act has become law, and the Department of Health and Human Services (HHS) has eliminated contraception from its list of essential preventive services that must be covered by insurance without cost sharing.
Let's imagine a woman named Margaret. She is 25 years old and has Type 1 diabetes requiring insulin. She has high-deductible health insurance through her job with a construction company. For the past 2 years, high out-of-pocket medical and prescription costs have led Margaret to avoid doctor's visits, and her sugar levels are too high.
Margaret and her fiance want to delay having children for a few years until they become more financially stable. Additionally, Margaret's doctor recommended that she delay pregnancy until her sugar levels are better controlled, to improve outcomes for both Margaret and a baby. However, because insurance companies are no longer required to fully cover contraception, her insurance charges a $100 copayment for an intrauterine device (IUD), the most effective reversible birth control method and a particularly safe option for most women with chronic medical conditions.
Unable to afford the copay, Margaret and her fiance use condoms. But -- as happens to 20 percent of women using condoms for birth control over the course of a year -- Margaret unexpectedly becomes pregnant. She delays initiating prenatal care due to the cost. Because of this delay and her high blood sugar levels, her pregnancy is complicated. She delivers her baby pre-term and he requires a neonatal ICU stay, which presents further emotional and financial challenges to her family.
Repeal of the Affordable Care Act's no-cost coverage of contraception will make stories like Margaret's all too common and will have harmful consequences for both babies and women -- especially the growing number of women who already live with chronic disease.
A sexually active woman of reproductive age has an 85 percent chance of getting pregnant in a year without birth control. Since contraception was included in the HHS's list of essential preventive services for women in 2012, most private insurers now must provide comprehensive contraceptive coverage without charging patients copays or deductibles. HHS estimates that since passage of the ACA, 55.6 million women now have access to contraception without copays. Although early research has not yet shown dramatic changes in contraceptive use post-ACA, in previous studies, eliminating contraceptive copays has increased women's use of the most effective methods, and reduced rates of unintended pregnancies and abortions.
Unintended pregnancies are associated with risks to woman and babies, including higher likelihood of delayed prenatal care and premature delivery. However, reduced access to contraception is particularly devastating for women managing chronic diseases like diabetes, high blood pressure, heart disease, and obesity. These conditions make pregnancy riskier and have contributed to the rise in maternal deaths in the United States seen in the last two decades. Some of the risks can be reduced by careful planning of pregnancy, including preventing conception until a woman is ready. Thus, enhanced access to birth control, along with maternity care and other women's health services under the ACA, has potential to help reverse that disturbing trend.
The current House Republican health care proposal would jeopardize women's access to essential preventive health services, including family planning, through reducing Medicaid coverage and benefits and by blocking federal reimbursements to Planned Parenthood. Further, the current requirement for no-cost coverage of contraception could be removed at HHS's discretion. These changes would be catastrophic for millions of women, and especially those who battle medical conditions already.
As primary care physicians at Massachusetts' largest birthing center, we see cases like Margaret's every day. The researchers, doctors, and public health experts who drafted the ACA's women's health provisions understood that contraception is essential to the long-term health of women and families. However, amid political and religious outrage over required coverage of contraception, lawmakers and activists often overlook the fact that planning pregnancy can save lives.
As Congress considers repeal of the ACA, patients and doctors must advocate for no-cost contraceptive coverage. Massachusetts has an opportunity to lead other states, with the Legislature's proposal of An Act Advancing Contraceptive Coverage and Economic Security in our State (ACCESS), which would mandate contraceptive coverage without copays for Massachusetts women with any health insurance. No-cost coverage works, and should be a component of any nation's commitment to its citizens' health.
Lydia Pace is Faculty Director of the Women's Health Policy and Advocacy Program, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital. Eve Rittenberg is Primary Care Medical Director, Gretchen S. and Edward A. Fish Center for Women's Health, BWH. The opinions expressed here are solely their own and do not reflect the views and opinions of Brigham and Women's Hospital.
