Contraceptive Equity and Access in the United States: a 2005 update
Findings from the 2002 National Survey of Family Growth, released December 2004, indicate the number of women who were at risk of pregnancy but not using a method of contraception increased from 5.4% (3.13 million U.S. women aged 15–44 years) in 1995 to 7.4% (4.56 million) in 2002. This trend (which was limited to women 20 years or older) is disturbing, will likely result in more unintended pregnancies and abortions, and begs the question ‘How can we improve access to contraception among U.S. women?’
In 1994, research published by the Alan Guttmacher Institute found that private insurance in the United States failed to adequately cover reversible contraception. Although virtually all indemnity plans covered prescription drugs, half covered no prescription contraception. Only one third covered oral contraceptives, and only 15% covered each of the most common reversible methods at that time (the pill, Depo-Provera, the copper IUD and the diaphragm). Although HMOs offered somewhat better contraceptive coverage, less than half covered the four methods indicated above. In contrast, almost 90% of private insurance plans at that time covered tubal sterilization, and about two thirds covered induced abortion .
Inadequate contraceptive coverage has important downsides for our patients and society. Financial concerns may cause women to forgo use of any contraception or use a less effective method strictly for reasons of short-term cost. The result: high rates of unintended pregnancies (one half of all pregnancies in the United States) and abortion (one fourth of all elective pregnancies). Unintended pregnancy is associated with higher perinatal and maternal mortality than intended pregnancies and contributes to poverty. In addition, women of reproductive age end up paying almost 70% more in out-of-pocket health care costs than do men of the same age, with reproductive-related expenditures accounting for much of this difference.
The Equity in Prescription Insurance and Contraceptive Coverage Act (EPICC) was introduced in Congress in 1997. This legislation, which has not been enacted at the federal level, would require all health plans that provide prescription coverage to cover FDA-approved contraceptives. A national poll conducted by the Kaiser Family Foundation in the late 1990s indicated more than three quarters of Americans supported such a requirement.
Since 1998, Congress has required insurance plans participating in the Federal Health Benefits Program, which covers more than 1 million reproductive-aged women, to cover all prescription contraceptives. As of early 2002, 18 states had enacted laws consistent with EPICC . By late 2004, this number had grown to 21, with several other states considering such legislation . Although more states have enacted legislation consistent with EPICC and insurance plans are increasingly likely to cover traditional contraceptives, legislation and insurance coverage have not kept up with progress made with respect to new U.S. contraceptive choices [5,6].
Since the new millennium, new contraceptives, including the progestin-releasing intrauterine system, the patch, the ring and hysteroscopically placed sterilization inserts, have received FDA approval and currently provide our patients with important new birth control options that do not require daily administration or use related to sexual relations. Although availability of these newer methods would appear to be cause for celebration, too often our patients cannot access them.
A 2004 nationwide survey performed on behalf of the Association of Reproductive Health Professionals, Black Women's Health Imperative and Planned Parenthood Federation of America found that, compared with more traditional contraceptives (e.g., oral contraceptives), insurance coverage was deficient for newer birth control options. In addition, the survey found that benefits managers were poorly informed regarding the newer contraceptive options listed above. For example, a recent study funded by Conceptus, which manufactures the new sterilization insert, determined that about 81% of employers cover oral contraceptives, 59% cover the patch, 40% cover IUDs and 36% cover the new hysteroscopic sterilization method .
Compared with nonuse, even with a time horizon as short as 1 year, use of any contraceptive method other than sterilization results in financial savings and health gains, with most of the financial savings and health gains due to the reduction in unintended pregnancies [7,8]. Hopefully, the federal as well as state governments, insurance companies and employers will recognize that by enhancing access to contraception, everyone wins.
*[not a free link] Kaunitz AM, Shields WC. Volume 71, Issue 5, Pages 317-318 (May 2005)
2. The Alan Guttmacher Institute . Uneven and unequal: insurance coverage and reproductive health services. New York: Alan Guttmacher Institute; 1994;.
4. Kaunitz AM. Fair access to contraception-legislation worth supporting. [Editorial]Female Patient. 2002;27(March):10–11.
5. Petersen A, Spencer J. The latest birth-control battle. Having won coverage for the pill, employees now press for insurance to pay for newer alternatives. Wall Street J. 2004;(October 26):D1.
6. Rodriguez P. Insurance coverage and reproductive health options (ARHP Contraceptive Corner). Female Patient 2004;29:44–6, 59.
7. Sonnenberg FA, Burkman BT, Hagerty CG, Speroff L, Speroff T. Costs and net health effects of contraceptive methods. Contraception. 2004;69:447–459.
8. Chiun-Fang C, Trussell J, Reyes E, et al.. Economic analysis of contraceptives for women. Contraception. 2003;68:3–10.