Out of Birth Control—At Least the Long-Term Kind

Beleaguered fans of the Affordable Care Act (ACA) got some encouraging news on Wednesday morning: The contraceptive mandate is working. A study released by the Guttmacher Institute, a think tank that supports abortion rights, revealed that the number of privately insured women who paid nothing out of pocket for birth-control pills nearly tripled since the fall of 2012, from 15 percent to 40 percent. More women are also getting the vaginal ring at no cost.

This financial bonus is courtesy of an ACA rule requiring private insurance companies to cover preventive care—like contraceptive products, procedures, and counseling—at no cost to the patient. Although some insurance plans are still “grandfathered in,” which means they don’t need to conform to the ACA’s requirements for now, millions of women became eligible for no-cost birth control at the beginning of the year, and they’re taking advantage of it.

There is some bad news sandwiched in with the good. Although the number of women who let their insurance company pick up the bill for their birth-control pills or ring increased substantially, the same was not true for other contraceptives like the IUD or the shot. What isn’t clear is whether this means women are choosing birth-control pills or rings over longer-acting methods like the IUD, or whether a delightful cocktail of insurer malice and provider incompetence is to blame.

The contraception mandate, infamous of late because religious business owners are begging the courts to let them wriggle free of its clutches, is a smart piece of policy because it allows women to choose the form of birth control that’s best for them, regardless of cost. The pill is the uncontested ruler of the contraceptive market, not because it’s best for preventing pregnancy (many women don’t remember to take it at the same time every day, which can reduce its success), but because of the low monthly bill. The IUD, a t-shaped device that, once inserted into a woman’s uterus, can last up to 12 years with no daily interference, has a much higher upfront price. The contraception mandate was supposed to make IUDs a viable option for more women by shifting the cost of the device and insertion to the insurance provider. But there’s no sign, at least from this study, that women are taking the plunge. Why?

Part of the problem, says Adam Sonfield, a senior public-policy associate and one of the co-authors of the study, could be “inconsistent” implementation of the contraception mandate by insurance companies—i.e. charging women co-pays for products and services that should be free. “Some insurers might not be treating every form of birth control identically, which obviously runs counter to the law,” he says. “There’s been some reluctance to cover contraception with upfront costs.”

But it’s hard to pin the blame entirely on the insurance companies. Judy Waxman, vice president for health and reproductive rights at the National Women’s Law Center (NWLC), a nonprofit advocacy organization with a hotline to help women when their coverage is denied, explains that because IUDs are expensive, many doctors don’t keep them in stock. This means that if a woman decides to opt for an IUD, she might need to pick up the device at a pharmacy, then return to her physician once for the insertion and again for a follow-up. “Some women find that annoying or difficult to manage,” she says. “Even though all the visits should be covered, they may not want to go to the doctor three times.”

Mara Gandal-Powers, an attorney for the NWLC who works on the hotline, says that other women have complained that although their IUD itself was free, they were hit with co-pays for the insertion procedure or follow-up appointment. She adds, though, that the people she works with are self-selecting. They only call if they’re having a problem.

It’s also possible that doctors simply aren’t presenting their patients with the full range of birth-control options. As I wrote in October, contraceptive counseling is technically covered under the ACA, but the reality is murkier; busy doctors with growing patient rolls often aren’t paid to spend an extra 30 minutes walking women through the pros and cons of each form of birth control. If a doctor is more familiar with the pill, that’s what they’ll recommend. The lack of counseling is especially dispiriting because many women seem to want an alternative to the ubiquitous pill, with its unpredictable side effects and once-daily regimen. The popularity of the vaginal ring, which women replace monthly, points to this yen for more variety.

Overall, the numbers are promising, especially since for many women, the contraception mandate has only been in effect for a year. But doctors and insurance companies will have to do more to ensure that not only are women getting birth control at no cost, they’re choosing the method that works best for them. “It’s clear lots of women want to take advantage of this,” says Sonfield. “The fact that we’re seeing such a rapid increase, despite all the hurdles, is pretty striking. But there are still lots of logistical hurdles, and no one can think that this insurance coverage guarantee will be the silver bullet.”

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