The Washington Post

Adam Sonfield discusses birth control coverage under new health-care law.

Jul 21, 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."

Should the cost of birth control be covered by insurance companies? Adam Sonfield chatted about these recommendations, if this is a big shift from what insurance companies currently cover and what this means for the new health-care law.

Related: Birth control coverage proposed for most health insurance plans

Should health insurance plans cover birth control?: Chat with a member of the committee who made the recommendation.

Welcome everyone, I’m looking forward to our chat about the Institute of Medicine’s recommendations for preventive health care. I’m a senior public policy associate at the Guttmacher Institute, an independent, nonpartisan research and policy organization in the field of sexual and reproductive health. Full disclosure: Guttmacher submitted extensive testimony to the IOM panel (PDF: Our testimony summarized the strong body of evidence showing that contraception is key to achieving healthier pregnancies and that planned pregnancies lead to better health outcomes for mother and baby. Among other things, we also documented that cost can be a significant barrier to contraceptive use.

How did birth control pills get excluded in the first place? If men can get their Viagra paid for by insurance, why not women? Why is a hard-on more valuable than a woman's right to control family size and a single woman's right to not get pregnant? This is outrageous!

Why was contraception excluded? That's a bit of a long story:
The provision of the health reform law we're talking about requires plans to cover a range of preventive health care services without additional out-of-pocket costs to the patient. The initial set of services-- which went into effect last September-- are based on three existing sets of recommendations about preventive health. They include many important services for men, women and children, from aspirin to prevent heart attacks to screening for depression to counseling about tobacco use.  (It does *not* include Viagra, by the way-- that isn't preventive medicine.)

Unfortunately, there was no existing set of recommendations for women's preventive health services, so that list had a lot of holes in it. That's what the Institute of Medicine panel was asked to do-- make recommendations to fill in those holes. Contraceptive education, services and supplies to help women plan and space their pregnancies was one of eight recommendations to do that. Assuming the U.S. Department of Health and Human Services agrees with the recommendations, they'll be added to that list of services that most insurers must cover, starting around a year from now.

I'm curious--are vasectomies generally covered? If they are, that kind of shoots down the argument that it's not covered if it's elective and not required to treat a disorder.

Yes, vasectomices are generally covered today by private health insurance plans. And, in fact, so are most forms of reversible birth control, such as the Pill, the IUD and the contraceptive shot. But there are still gaps in that coverage-- we worry especially about plans bought in the "individual" market (rather than insurance you get through the workplace).

And beyond that, this provision of the health reform law doesn't just require coverage for dozens of preventive services--  it also requires insurance plans to cover them with no additional out-of-pocket costs for the patient. Those additional costs-- copayments and deductibles-- can amount to hundreds of dollars per year when it comes to contraception. Eliminating out-of-pocket costs should help ensure that women and couples can select a method of contraception that works best for them, so that they can most effectively plan and space their pregnancies. And that's the whole point of this preventive health provision-- by eliminating the additional out-of-pocket costs, we knock down one more barrier to using effective preventive care services.

I'm curious why condoms weren't recommended. I understand that they're not prescription, but no one could argue that they're not "preventative care." Is there any initiative to offer low-cost or no-cost condoms under insurance plans?

Actually, the IOM's recommendations don't specify that they're only about prescription drugs. But whether insurers will need to cover condoms will be up to the decision makers at the Department of Health and Human Services.

Health insurance companies are about spreading the costs of health risks over large groups, so that individual policyholders aren't left destitute by catastrophic illness. Insurers already cover the costs of preventative care, often with no copays, because these help reduce risk and decrease costs to all policyholders. From that standpoint, including birth control coverage makes sense. Pregnancy involves health risks for the woman, so preventing unwanted pregnancies is simply another risk reduction measure. Why treat this differently from any other type of preventative care?

Well said. And in fact, that is exactly how the IOM panel made its decisions-- it weighed the evidence about the effectiveness of contraceptive services and supplies the same way it weighed that evidence for all other women's preventive services.

It's a pity that no one is talking about the other women's health recommendations. For instance, breastfeeding has at least as many health benefits to woman and child as preventing unplanned pregnancies, and the potential financial benefit is much greater simply because contraception co-pays are generally not all that large and nursing support is very expensive.

Absolutely. That's the most frustrating part of the news coverage over these groundbreaking new recommendations. They'll help women make use of critical preventive care services throughout their lives, including before, during and after pregnancy. The recommendations also, for instance, address counseling about HIV and other sexually transmitted diseases, screening for diabetes during pregnancy, and more.

This should be 'Pay to Play". Those who don't get to "play" shouldn't have to pay for somone elses birth control or sex aids. Just because some want their sexual fun dosen't mean that the cost should come from taxpayer funds.

A few points:

First, sex is a basic part of human life. About 95% of Americans end up having sex before marriage, and virtually all of them have relied on contraception at some point in their lives.

Second, buying insurance doesn’t give someone the right to veto other peoples’ health care decisions. You may disagree with a host of health care-related decisions that other people make, such as smoking or diet or riding a motorcycle , but our right to disagree is not a right to interfere.

Third, planning and spacing pregnancies has crucial implications for the health and well-being of women, infants and families, and also has significant benefits for employers, government and all of society. And even if all you care about is cost, covering contraception is most likely going to save everyone money-- because the costs of unplanned pregnancy are far, far higher.

Can you explain the health risks of not covering contraception, with specific regards to women in poverty? How will the IOM recommendations impact women who do not have insurance, or who are on Medicaid?

Unintended pregnancy can pose substantial health risks for women and their children. Short intervals between births have been linked with numerous negative perinatal outcomes, including low birth weight and preterm birth, both of which are widely-acknowledged risk factors for infant mortality.  Unintended pregnancy generally has been linked with other negative outcomes, such as reduced breastfeeding and delayed initiation of prenatal care. Moreover, several studies also suggest a potential association with subsequent child abuse, maternal depression and marital instability.


Unfortunately, the IOM recommendations will not help uninsured women-- but hopefully, the rest of the health reform legislation will do so. And Medicaid, btw, already has strong coverage for family planning services, without out-of-pocket costs for women.

Should the HSS take the IOM's recommendation, will only new insurance plans under the reform in 2014 be affected? I'm wondering about women who already possess insurance plans that do not currently provide coverage, or do not provide coverage without an additional co-pay.

Actually, the original list of requried preventive services took effect last September,  although in practice they are being phased in more gradually, for two reasons: First, they become effective only at the beginning of a new plan year, which for most group plans is January 1. Second, plans are "grandfathered"—exempt from the requirement—so long as no significant, negative changes, such as cutting benefits or raising cost-sharing, are made to them. This will be true for the new women's services, too-- starting a year from when HHS makes its final determination. HHS has said that they expect most plans to lose grandfathered status within a few years.

Just wanted to say that I deeply appreciate the work that the Guttmacher Institute does on behalf of women's health and equality. It's also great to see a man sticking up for women's reproductive rights. It seems like a no-brainer to me that in 2011, everyone benefits from a woman's ability to decide whether and when to have children, but unfortunately the forces against us are still strong, and we need organizations like yours to follow legislative, judicial, and medical developments. Keep it up!

Thanks so much!

People who object to contraception for religious reasons claim covering it violates their rights of conscience by forcing them to pay for something they think is wrong. How would you answer that argument?

See my answer above. Insurance would basically become unworkable if everyone got a veto over what services any other member of the insurance pool could use.

Paying for BC discriminates based on sex. Will it cover condoms if you are male or Viagra? BC should be an out of pocket expense and not covered by your health insurance ever.

It takes two to tango. Just because the woman is the one using the contraceptive method, it doesn't mean she's the only one who benefits.  But yes, we do hope that this will cover condoms as well-- and that in the future, when we finally get other male methods, that HHS will make sure that those are covered, too.

To the questioner about having to pay for birth control: you're either a man or a woman whose menstrual cycle is regular like clockwork. There was a period of time I was off the pill for a couple of years (not in a relationship), and it was two years of hell -- irregular periods, painful cramps, anemia, you name it, I went through it. Missed work because of it. Went back on the pill, physical problems went away. Birth control isn't just for pregnancy prevention.

The argument can be made that birth control pills serve as more than simply contraceptives--they can be taken by women to lessen menstrual pain, help with anemia, lessen the odds of infection, etc. This makes perfect sense for preventive care. What about other forms of contraception, such as IUDs, hormone injections, the patch, the ring, etc.? Will those be covered as well?

The IOM recommendations were to cover the full range of FDA-approved contraceptive methods. That would include all of the ones you list. And yes, there are other benefits of specific methods, and that's one factor that women and their doctors will be able to take into consideration-- without having to worry about out-of-pocket costs. (But remember, HHS still has to make the final decision.)

I'm wondering what the likelihood is that HHS adopts all of these recommendations. In general, does HHS follow the IOM's lead? And if so, could contraception coverage be excluded anyway because of its "controversial" nature?

HHS has said that they'll make a determination very soon, and had set an August 1 deadline. So, we'll see. But if they make their decisions based on the science, the answer should be clear.

is to spread risk and cost among a varied population. It wouldn't be "insurance" if everyone got to pick and choose what services they and everyone else would get. It's the same as with taxes; I don't want my federal income tax to fund wars, but I don't get to make that choice.

If the HHS does decide in favor of the IOM's recommendation to include all FDA-approved contraceptive methods as preventive care, to be covered without co-pay by all private insurance plans, how possible do you think it is that we will see legislative restriction prior to 2014 that attempts to limit or retract the decision?

The debate over contraception on main street America has long been settled. 99% of Americans who have had sex have used contraception-- and the number is virtually the same regardless of religion.


Unfortunately, Congress hasn't always gotten that message. And so, yes, it's probably safe to assume that some foes of contraception will propose some new restrictions on contraception. What will come of that remains to be seen.

I took them since I was VERY young due to horrible ugly pain when I ovulated. It was crippling, much more than (I've heard) menstrual cramps are. There are many women who take BCP for medical reasons, actually.

I'm dismayed that some large big government organization is making these decisions.  It's crazy and it's micromanaging. *sigh*

This won't be forcing anyone to use any health services they object to. The whole point of this-- not just for contrception, but for dozens of other preventive care services-- is to empower women (and men) to make responsible decisions about their own health and lives.

I like your answer regarding insurance risk, but there's a more basic answer. The government engages in all sorts of activities that violate my rights of conscience. Bombing Libya, invading Iraq, holding people in prison without charging them, etc. I pay for a lot of things I think are wrong. That's the nature of democracy.

A number of people are submitting comments along these lines.

Hi Adam! As a former employee of NFPRHA, I was so excited to see the IOM recommendation. I know Guttmacher has excellent information regarding state laws and how they influence whether insurance companies cover birth control at all, and I was wondering if you could comment on how this recommendation might affect that. Specifically, I know many states that make birth control coverage mandatory also offer a religious exemption for organizations that may be opposed to artificial birth control. Do you see these exemptions as holding up if coverage becomes mandatory on a federal level?

That's right, there are 28 states that already have laws requiring insurance plans to cover contraception if they cover other prescription drugs. And 20 of them allow some organizations (typically religious employers, such as churches or religious schools) to opt out of that.  See our fact sheet here:

Generally speaking, federal law preempts state law, so we'd expect that plans governed by this new preventive services requirement would have to follow the federal law. Some existing plans are exempt from the federal law, at least until they make big enough changes to lose their "grandfathered" status.

Why should abortion and birth control be considered as women's basic health care, while both aren't dealing with an illness?

re: the health benefits of contraception, see my answers above.

But if you're concerned about reducing the need for abortion, then you should strongly support better access to contaception.

There is a wealth of evidence demonstrating the obvious: Contraceptive use dramatically reduces unplanned pregnancy. By doing so, it also dramatically reduces abortion, since behind almost every abortion is an unplanned pregnancy. Guttmacher Institute research shows that the two-thirds of U.S. women at risk of unintended pregnancy who use contraception consistently and correctly throughout the course of any given year account for only 5% of all unintended pregnancies.

The policy implications are clear: Helping more women to become effective users of contraception is key to reducing both unintended pregnancy and recourse to abortion. The IOM recommendations could be an important step toward that goal. By making counseling, patient education and contraceptive services and supplies available under private insurance plans without cost-sharing, the new guidelines help reduce a key barrier to better contraceptive use that many women face. This is true especially for the most effective methods, like the IUD.

What are the strongest arguments against having contraception covered? IOM took a scientific, medical approach to their recommendation-- is there a medical reason not to, or do the 'con' arguments revert back to individual feelings or beliefs?

The IOM recommended that the “full range of Food and Drug Administration–approved contraceptive methods” be made available without cost-sharing. All drugs approved by the FDA have already undergone an extensive assessment of benefits and side effects—and experts have concluded that the benefits strongly outweigh any side effects.

Also, you should not focus exclusively on negative side effects. There are multiple, significant benefits to contraception other than allowing women to time and space their pregnancies. For instance, see this statement from the Ovarian Cancer Network on the IOM recommendations: “The research is clear: oral contraceptives can reduce a woman’s risk of developing this disease [ovarian cancer] by as much 50 percent.”

So, yes, all of the major arguments being used by opponents of covering contraception boil down to matters of ideology or moral objections. It's important to remember that Americans overwhelmingly support and use contraception, including those with strongly held religious beliefs.

I don't see a huge outcry about my insurance costs going to people who smoke, drink, and live on junk food, but Americans seem to be obsessed with the idea that some people might be having sex, which as Adam pointed out is a basic fact of life. Isn't it far more "government interference in private affairs" to lobby to refuse coverage of an essential component of the health of a large segment of the population?

What will be the economic effect if HHS chooses to provide the recommended preventive services at no additional cost?

Many women and couples who rely on these preventive services-- not just contraception, but annual well-woman visits, counseling about sexually transmitted infections, assistance for breastfeeding, and more-- would no longer be faced with potentially hundreds of dollars of additional out-of-pocket costs, beyond the premiums they pay each year.
For employers and insurers, some of the preventive services-- including, most likely, contraception-- will end up saving money overall. We know, for example, that every public dollar spent on contraceptive services ends up saving the government nearly $4 in pregnancy-related costs.
But even without the cost-savings, all of these preventive services are ones to be encouraged because they will help improve peoples' health and well-being. And that's the point of covering these services in the first place.

Those who think contraception coverage is frivolous or economically unjustified should look at history. For hundreds of thousands of years, women's lives between menarche and menopause were overwhelmingly defined by frequent childbearing--and often ended by it. Any one of us can look at any history book about the lives of ordinary people anywhere, or at our own family history before, say, a hundred years ago, and discover the truth of that statement. For that reason, the contraceptive revolution has been as enormous and as important for women as the agricultural or industrial revolutions were to humanity as a whole. Women's ability to live their lives free of biological imperatives depends on contraception, and for that most basic health need not to be provided by health insurance is an absurd injustice. Thank goodness, this decision will at last correct it for American women--and the men who value them as equals in any sphere of life.

For example, in addition to its contraceptive use, I take BCPs to control ovarian cysts. I've lost one ovary already; if I lose the other, that could lead to a whole host of lifelong health issues. I'm 30. It's got to be cheaper for my insurance company to pay for my birth control pills than it would be to pay for the major health issues I could face without them. That's not to say that contraception isn't an important issue. It absolutely is. But there are other reasons to take birth control pills, too. Thanks to the IOM for the thorough investigation of this matter.

My insurance currently "covers" birth control, but the copays are significantly higher for the patch and the ring than for pills, because there are generic pills on the market. Can I expect the preventative care designation to change the copay structure? I'm also curious whether this would likely lead to breast pumps without copays.

That really is the point of this provision generally-- to eliminate those copay barriers to using services that are right for you. The IOM's recommendation-- by including the full range of methods-- should end up leveling the playing field among different types of birth control. (Assuming HHS adopts these recommendations, of course.)

Thanks, everyone, for the many great questions. If you wish to stay in touch with Guttmacher’s work, please consider following us on Facebook ( and Twitter (!/Guttmacher)

Stay cool out there!


In This Chat
Adam Sonfield
Adam Sonfield joined the Guttmacher Institute’s Washington, DC office in 1997 and currently serves as a senior public policy associate. He is the managing editor and a regular contributor to the Institute’s public policy journal, the Guttmacher Policy Review. Mr. Sonfield’s portfolio includes research and policy analysis on public and private financing of reproductive health care in the United States, the rights and responsibilities of health care providers and patients, and men’s sexual and reproductive health. He also writes a quarterly Washington Watch column for Contraceptive Technology Update. Mr. Sonfield earned an A.B. with honors in social studies from Harvard University and a Master of Public Policy, focusing in health policy, at Georgetown University.
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