Should health insurance plans cover birth control?

Jul 20, 2011

The National Academy of Sciences' Institute of Medicine recently made recommendations for women's coverage under the new health care law, which include free coverage of prescription birth control, including "the so-called morning-after pill sold as Plan B and the more recently approved drug sold as Ella."

Dr. Linda Rosenstock, one of the committee members who made the recommendation, chatted about the research that went behind the decision and why the committee thinks birth control should be covered under the new health-care law. Related: Birth control coverage proposed for most health insurance plans

Chat with Adam Sonfield on Thursday about this recommendation, what it could mean for the new health-care law and whether or not having insurance companies cover birth control is a good idea.

Hello, this is Dr. Linda Rosenstock. I'm pleased to represent the full committee of experts who together conducted this evidence review and wrote this report on preventive health services for women. Our task was to determine if there are any gaps in the preventive health services specifically for women in the Dept. of Health and Human Services' comprehensive list of preventive services. And we were tasked to recommend any missing services that evidence shows are effective and that work to promote women's optimal health and well-being. We identified 8 services to fill gaps in HHS's comprehensive list. I'm happy to take your questions about any of these recommendations, including our recommendations to prevent unintended pregnancies, which account for half of the pregnancies in the U.S. each year. Unintended pregnancies increase women's risk for several health problems and also increase the risk of babies facing health problems after birth.

All of the various hormonal contraceptive advertisements are accompanies by lengthy disclaimers regarding the risks of blood clots, heart attacks, and strokes resulting from the use of the contraceptive. When you made this recommendation, was there any study regarding the increased number of these medical conditions that would result from making contraceptives freely available and how much those conditions would cost to treat? Any idea how many of these conditions occur in the US each year today and what the annual treatment costs are?

Our task was to assess what services improve women's health.  In this recommendation as with others we had to consider the possible benefits and harms of each service we recommended.  For women with certain medical conditions or risk factors, some contraceptive methods may be a better choice than others.  This is why education and counseling are critical components of family planning services.  By recommending the full array of FDA approved methods, a physician and patient can then decide for those women who wish to use some method, which is the best choice.

This may be more of a comment on the Washington Post than a question for the host of this chat, but in more than one place this law is described as providing "free" birth control. Nothing is free. If heath insurance plans are going to be required to provide a certain medication or treatment to anyone who wants it, everyone else on the plan subsidizes that medication or treatment. Describing it as "free" is not only inaccurate, but also injects bias into the discussion because, really, who WOULDN'T want something that is truly free?

You are correct.  The recommendation our committee made for consideration is not that services be free, but rather that when insurance plans offer these services they should be provided without co-payment (sometimes known as "first dollar coverage").  This is consistent with other preventive services in the health reform legislation.

I agree with your recommendation! I pay nearly $500/month for health insurance coverage and have to pay my prescriptions out of pocket on this high-deductible plan. I had discussed some issues with my health care provider who suggested a different, brand name birth control (a switch from the generic formulation I was using). I actually felt much better. However, I couldn't afford to continue taking the brand name medication, so have gone back to generic as a result.

I definitely agree that birth control should be free! I hate it that the majority of the cost of pregnancy prevention rests on women when men benefit just as much. One question: I recently decided I wanted to move from the pill to an IUD. Right now I've been told my insurance MIGHT pay for it. If it does not pay for it entirely now, though, I would prefer to wait until it has to pay for it. Any idea on how long that might be? I've heard plans that were created before Sept. 2010 will be grandfathered in but once they change, they'll have to cover birth control in full like everyone else. I'm not even sure when my plan was created - how should I find out?

This is a good question.  The timing for when services will be included -- for those services that the Department of Health and Human Services support including -- is phased in over several years.  Probably asking questions directly to your insurer will provide the best answer about your own particular situation.

I hope people understand that birth control is one of the more effective things that can be done to lower health care costs. Unintended pregnancies, abortions, miscarriage follow-up care, etc. And let's not even touch the indirect cost savings, such as higher crime rates for children of unwed and/or teenage mothers, etc.

Can you explain what medical condition birth control is intended to cure? My understanding of biology is that if a woman becomes pregnant as a result of sex, her body is acting properly. There is nothing broken or malfunctioning that the pill is intended to fix. Probably 99% of women who use contraception use it as a lifestyle choice, i.e. they want to have sex without getting pregnant. Why should everyone else have to pay for that lifestyle choice?

It is important to understand that our committee looked at the evidence for what services work to improve women's health.  Unintended pregancy accounts for about half of all pregnancies in the U.S. each year and these pregancies can cause health problems for both the mother and the newborn.  There is compelling evidence that contraception counseling and methods are very effective ways to avoid unintended pregnancies and to allow women to optimally space their pregancies. 

Currently, what extra burden does the average woman face in preventing unwanted pregnancies? How does this push to get birth control covered in full relate to the defunding of planned parenthood, which provides birth control at little to no cost already?

I appreciate your comment but you raise questions beyond the scope of our committee's charge.  We do know that providing first dollar coverage for effective preventive services will mean that more women will have access to using them.

Why hasn't health insurance covered birth control? What have been the historical arguments/reasonings against it? I can't help but believe it would be a wash if not a benefit to the insurers--if one weighed the costs of BC vs the cost of more, unintended pregnancies.

Indeed most health insurance plans do cover family planning services.  But even for those, most were accompanied by co payments (for example, $25) for the medication each month.  This is seen as a barrier to  a woman availing herself  of the method most suited to her individual needs.

Let's be clear here buddy - women are not the only ones involved here. Even if it is a lifestyle choice, it is a choice that affects both woman AND the men with whom they have sex. But it is only the women who have to bear the burden of making sure there is some protection. Who is the "everyone else"? The men who should be paying for part of this "choice" to begin with?

Why is this a question at all? Do people not realize that the costs of unwanted pregnancies are MUCH, MUCH greater than the cost of insurance covering birth control? It's not just the health care costs of unwanted pregnancies that we should consider, (which burden all of us if the parents are un or underinsured).

Although our committee made  recommendations based on the evidence of health improvement independent of costs, I believe there is a very good discussion in the report in Chapter 5 about some of the issues you raise and about the cost savings that can accrue in avoiding unintended pregnancies.

According to a 2002 study by the Alan Guttmacher Institute, of those women who did not use contraception the month they got pregnant and chose to have an abortion, only 12% reported that cost was a factor in their decision not to use contraception. In addition, states and the federal government (via grants) already subsidize birth control for individuals with low incomes. Given that cost is apparently not a big factor in the decision to use birth control, and that we already subsidize this for individuals in need, why did the committee choose to recommend requiring first-dollar coverage for a service that apparently will go to benefit people who already use birth control regularly and have no fiscal need for the subsidy?

Our committee was limited in our charge to assess the evidence of what services would improve women's health.  In that regard family planning services are well founded as effective measjres.  Some of the issues you raise are important but beyond the scope of what we addressed.

Invest in preventing unwanted pregnancies now = savings in healthcare use of full term pregnancies, NICU + savings for businesses as fewer people take maternity/FMLA leave :)

You state that "In this recommendation as with others we had to consider the possible benefits and harms of each service we recommended. " However, you did not answer the question on heart attacks, strokes, etc. How were those risks quantified so that they could be weighed against the benefits? Can you provide that analysis such as through a link to the underlying numbers and associated medical costs?

The committee is well aware that some of the recommended services have both benefits and harms.  Our review of the medical evidence was focused on assuring that any recommended service had significant net benefits to women, but we recognize the importance of an individual woman in consultation  with her provider choosing the best and safest method for her personal situation.

Health insurance is (hypothetically) about spreading costs and risks among large groups of insurers so that no one member is left destitute by catastrophic illness. It's not just the cost of unwanted pregnancies, it's also the health risks associated with pregnancy and delivery, and reducing the numbers of unwanted pregnancies will reduce those risks as well.

The chatter who suggested that women using contraception have made a lifestyle choice that should not allow for preventative medicine might want to consider the slippery slope that covers. The American Heart Association says that heart disease is 80 percent preventable, if people would do things like smoke less, eat healthier, and exercise more. In other words, lifestyle choices. The same is true of obesity, type 2 diabetes, and some types of cancer. Should treatments for those conditions be denied, as well?

Does you recommendation cover non-medical forms of contracetion such as the sympto-thermal method of Natural Family Planning or otherwise abstaining during the fertile periods of a woman's cycle. Once you learn these methods, they are essentially free and do not have the side effects of hormal birth control.

Our recommendations were based on considerering what services provided in the physician's office or other clinical setting are effective.  As such, we recommended including counseling (which could cover a broad discussion of possible interventions) and all FDA approved methods and devices.

I appreciated the opportunity to chat and for your many thoughtful comments and questions.

In This Chat
Linda Rosenstock, M.D., M.P.H.
Linda Rosenstock (elected to the Institute of Medicine [IOM] in 1995) is dean of the School of Public Health, University of California at Los Angeles (UCLA). She is a recognized authority in occupational and environmental health as well as global public health and science policy. Prior to going to UCLA in 2000, Dr. Rosenstock served for 7 years as the director of the National Institute for Occupational Safety and Health, where she led a staff of 1,500 at the only federal agency mandated to undertake research and prevention activities in occupational safety and health. In recognition of her efforts, Rosenstock received the Presidential Distinguished Executive Rank Award, the highest executive service award in the federal government. In 2003 she cochaired the IOM committee addressing public health workforce needs that authored the report Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Dr. Rosenstock is immediate past chair of the Association of Schools of Public Health and immediate past president of the Society of Medical Administrators.
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