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The Birth Control Conundrum

The image of a table of men — primarily from religious organizations — comprising a hearing devoted to birth control, became a snapshot emblematic of problems to follow. Rep. Carolyn Maloney (D-NY) asked the obvious question when she inquired incredulously, “Where are the women?”

Attempts by Sandra Fluke, a college student that had hoped to speak about the wide role of birth control medicine in women’s health, had been rebuffed with the statement that she wasn’t “qualified to testify.” She has since been publicly vilified by Rush Limbaugh.

For many, there was confusion about the whole conversation. Religious freedom was being pitted against women’s rights to basic health care. What exactly did it all mean for those of childbearing age?

In August 2011, a panel of experts from the Institute of Medicine had addressed how making contraception available would help impact the high rate of unplanned pregnancy. Congress enacted a women’s preventative services coverage requirement as part of the Affordable Care Act.

Studies have shown that women with private insurance were paying approximately 50 percent of their total cost for oral contraceptives, compared to 33 percent for usual out-of-pocket costs for other drugs. In addition, women of reproductive age spend 68 percent more on out-of-pocket costs than men. 

I contacted a range of professionals in the areas of medicine, law, and policy to get a clearer picture of the issues involved. Along the way, I learned a number of surprising statistics, including the high number of unplanned pregnancies in the United States — 49 percent. 

My first two inquiries were with medical practitioners located in disparate parts of the country.

Dr. Ringland S. Murray, a Reproductive Endocrinologist who is Board Certified in Obstetrics and Gynecology, practices in Tennessee. He told me, “I don’t have a political axe to grind, but I don’t get it from an economic standpoint. It’s bewildering that this would be a battle. It’s a lot more expensive to have a baby than for pills to be supplied to women.”

He continued, “If this is a question of holding down health care costs, it's more cost effective to prevent pregnancy, especially in high risk groups such as those who are economically disadvantaged. These individuals frequently have higher risk pregnancies with more complications and therefore, more costs."

Outlining the numerous health benefits of oral contraceptives Murray explained, “There are lots of health care reasons to prescribe birth control. For endometriosis pain, it prevents the loss of workdays. It reduces the risk of ovarian cancer by 40 percent as opposed to non-users. The protection lasts for up to twenty years, even if the pills are used for as few as three to six months. It has been used safely by women with BRCA mutations. Birth control pills have been associated with a 40 percent reduced risk of colorectal cancer. They can be used in a diversity of ways. It depends on the women and her medical condition.” 

Noting the high cost of purchasing birth control, Murray said, “Brand name birth control pills are very expensive, approximately $50 to $60 per month. They are not real affordable for a lot of women. There is tighter control over these, whereas the generic low-dose pills — which can run $25 per month — may be less effective. If you are not willing to pay for birth control, you are putting your employees at increased risk for pregnancy.” Murray said, “If it is available and affordable, there are fewer unintended pregnancies —  the number one reason women seek abortion. Birth control has a 5 percent failure rate. It is better than condoms. If you are against abortion, you should be pro-birth control.”

Murray reflected, "In some ways, the Affordable Care Act could go farther. Studies have shown that to have the greatest decrease in unintended pregnancies, we should provide three to six months of contraception at a time, so women don't miss days between pill packs. Women who must go to the pharmacy every month are at increased risk for missing pills and getting pregnant. But at the current asking price, how many women can afford three to six months worth of pills at a time?"

With a touch of irony, Murray related that birth control pills work similarly to breastfeeding, a natural form of contraception for about eight weeks after a woman delivers a baby. After birth, when a woman breastfeeds, her prolactin is high. This does not always prevent ovulation or fertilization of an egg, yet still offers contraceptive protection. He added dryly, “Are you going to legislate breastfeeding?”

Barbara Dehn, a Registered Nurse and Nurse Practitioner based in San Francisco, also pointed to the use of birth control pills for health maintenance. “I’m caring for older women using birth control to stabilize hormone levels as they enter perimenopause, with its attendant wide hormonal swings,” she informed me. She also prescribes birth control pills for acne, dysmenorrhea, irregular periods, PMS, and to help prevent migraines that accompany hormonal headaches. She has to be very clear how she is prescribing the medicine, as her charts can be audited and she has to stay within the letter of the law.

What Dehn has been hearing from her patients is complaints about bearing the burden of birth control and what they perceive as a double standard. She related the story of a patient in her late 20s who objected, “I pay for my health insurance. It should cover my birth control. Men with the same insurance at work get Viagra with no co-pay.”

Reiterating the concerns of Murray, Dehn underscored, “Co-pays are onerous. Women struggling financially can’t afford co-pays for birth control or to manage their symptoms. Women aren’t using their pills consistently. They may skip a couple of months. During that time, they may not use a backup method.”

Citing the obvious, Dehn said, “Men can make any decision they want because they don’t carry a baby.” She observed, “It’s maddening. We have a hyper-sexualized society, [yet] there is a small vocal minority that only wants women to have sex to procreate.”

On Thursday, March 1, a showdown on the Blunt Amendment took place with a vote in the Senate. It sought “To amend the Patient Protection and Affordable Care Act to protect rights of conscience with regard to requirements for coverage of specific items and services.” In essence, it meant that an employer would be allowed to refuse coverage on any medical service they had a moral or religious objection to. It would allow health insurance plans to deny coverage of care if it was against the policy issuer’s beliefs.

I contacted Laura MacCleery, the Director of Government Relations at the Center for Reproductive Rights for her thoughts on the proposed legislation. MacCleery was clear about her concerns. “People should realize that many of the rights women thought were settled in the past are up for grabs. There is a well-funded coordinated effort on this. The fact that this is 2012 is astonishing.” She continued, “Women aren’t aware of the threat to services they take for granted. The mantle of religious liberty is being used to deny women access to public health.”

The Director of the Women’s Health and Rights Program at the Center for American Progress, Jessica Arons, characterized the amendment with the assertion, “It’s out of step with the times.” Echoing the concerns of those in the health field, Arons said, “The Affordable Care Act guarantees women birth control access without cost sharing. Women know that birth control can be very expensive. The Guttmacher Institute has shown that women have used their prescriptions inconsistently to save money. Often, they choose less reliable methods — based not on medical decisions but on cost factors.”

Accessibility and affordability is key. Betsy Havens, an attorney and Equal Justice Works fellow at Florida Legal Services in Miami, sees this first hand.  She is a founding member of the Miami Health Equity Project. She said, “Women and families deserve access to quality, affordable health care including preventive services and birth control.  For many women in Miami and across the United States, financial barriers and co-pays often inhibit the ability to regularly access birth control and other essential medical needs. The Affordable Care Act helps women of all incomes, but it is especially important for low-income women. This is essential to the health of our nation, where approximately half of all pregnancies are unintended, in part, due to lack of access to affordable birth control.” 

Havens mentioned the proposal put forth by Sen. Marco Rubio (R-Fla), the “Religious Freedom Restoration Act,” that would allow any institution or corporation to cut off birth control coverage by citing religious grounds. Figures show that in 2006, 59 percent of pregnancies in Florida were unintended.

There have been a number of polls trying to tap the pulse of the American public on opinions related to the birth control question. A CBS/New York Times Poll (Feb. 8-13, 2012) showed in response to the question, "Do you support or oppose a recent federal requirement that private health insurance plans cover the full cost of birth control for their female patients?" that 66 percent were in support and 26 percent opposed. When queried about “for religiously-affiliated employers, such as a hospital or university?” the response was 61 percent in support and 26 percent opposed. The Quinnipiac University Poll (Feb. 14-20, 2012) asked, “Do you think that health insurance plans should cover birth control as preventative care for women or not?” and found that 71 percent felt it should and 24 percent felt it should not. When asked if the “federal government should require private employers to offer free birth control coverage as part of their health insurance benefit plans or not?” 47 percent felt employers should, while 48 percent felt employers should not.

The vote on tabling the Blunt Amendment resulted in the bill being defeated by a vote of 51-48.

Wondering if this was the beginning of the end of a prolonged conflict about health coverage for birth control, I reached out to Lisa Maatz, Director of Public Policy and Government Relations for the American Association of University Women. She responded via e-mail, “In a perfect world, the defeat of the Blunt Amendment would put an end to this nonsense. However, not only are we not living in a perfect world, we appear to have entered a time warp back to the 1950s. AAUW believes strongly in balancing freedom of religion with the separation of church and state. The accommodation recently made by the Obama Administration regarding birth control struck that balance. Other bills want to tip the scales so far that women’s health care is compromised, and that’s simply unacceptable.”

In this volatile election year, it looks as if the story is far from over.

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