Popping the Pill's Bubble

As the Affordable Care Act creaks into gear-and the Obama administration sends its armies of tech elves into the back end of the Healthcare.gov website to deal with the glitches-newly insured women can, for the first time, begin to start thinking about what kind of birth control they want, rather than what they can afford. Under Obamacare, all forms of female contraception will be offered without a co-pay to insured women as part of a larger package of preventive-care services. The logic behind the "contraception mandate" is so simple it's hard to believe insurers didn't come up with it themselves. If women can choose a form of birth control that works for them, without worrying about the cost, they'll be less likely to get pregnant, saving insurance companies thousands of dollars in sonograms and prenatal vitamins.

Obamacare has the potential to end the birth control pill's dominance over the contraceptive market. More than 8 in 10 women will use a contraceptive pill at least once during their reproductive lives, although it's not as good at preventing pregnancy as many women assume. User error is largely to blame; for the pill to be fully effective, women need to take it at the same time every day, a challenging task even for the most organized among us. It also has unpleasant side effects like weight gain and loss of libido. But the pill has one massive upside: It's cheap. Even for women without insurance, a generic version of the pill can cost as little as $20 a month. It's not an insignificant expense, and it adds up over time. But for women who can't afford to pay hundreds of dollars up front for a contraceptive like the IUD-a T-shaped device that, once inserted into a woman's uterus, can prevent pregnancy for up to 12 years-the pill is a more affordable option.

All of that is about to change. Under the Affordable Care Act, insurance companies are required to cover at least one form of all FDA-approved contraceptive methods-including IUDs and contraceptive implants, matchstick-sized rods that are inserted into the arm to prevent pregnancy and last for up to three years-at no cost to their subscribers. These longer-acting forms of birth control are more effective at preventing pregnancy than the pill, and thanks to Obamacare, their large up-front cost is no longer an issue; it's no wonder that Bayer and Teva, two of the country's biggest contraceptive companies, are sinking millions of dollars into IUD advertising.

But for the women who are suddenly confronted with a cornucopia of scary-sounding contraceptive options-patches and implants, shots and rings-just having access to these new forms of birth control isn't enough. They need doctors to guide them through the process of choosing a new form of contraception, a role that physicians, who are already pressed for time, are ill prepared to fill. A survey released by the American College of Nurse-Midwives (ACNM) earlier this month found that 40 percent of women between the ages of 18 and 45 didn't receive in-depth counseling or information from their health provider on how to use the birth control they were prescribed. Of the 64 percent of women surveyed who said they were presented with multiple birth-control options (which means, conversely, that more than one-third of women were not), 1 in 10 reported that they felt pressured to choose one over the other. An additional 1 in 10 said they had questions they did not feel they were able to ask their health provider.

The survey's findings raise a troubling question. Now that cost is no longer a factor for women with insurance, will doctors inadvertently prevent their patients from finding the form of birth control that works best for them? Lisa Kane Low, an associate professor at the University of Michigan School of Nursing and a member of the ACNM committee who helped design the study, says it's not a matter of careless or malicious providers failing to offer information to their patients; the medical system simply isn't set up to provide adequate contraceptive care. The Affordable Care Act requires insurers to cover counseling as well as the birth control methods themselves, but it's not yet clear whether insurers will pay doctors extra for longer counseling sessions, an incentive that could make the difference between a 5-minute and a 20-minute appointment. "Medical care is driven by what's quick and fast," Low says. "It's much easier to write a prescription for a birth control pill than to sit down and talk with a woman about the pros and cons of the IUD."

Even though most women are seeking birth control because they're having sex, health-care providers rarely warn women about contraceptives' sexual side effects, which include decreased libido and vaginal dryness. "There's no acknowledgment that sex might be something people enjoy," says Jenny Higgins, an assistant professor of gender and women's studies at the University of Wisconsin. "When providers talk to women about sex, it's almost always through the lens of contraception alone-as if people are having sex for the sake of using contraception." As a result, most women are unaware that birth control pills can be a turnoff.

Part of the problem is that there's little emphasis on contraceptive counseling or education in medical school. Higgins says that doctors may be uncomfortable asking women about their sex lives because they're worried about invading patients' privacy. Women, in turn, aren't used to thinking about contraception as something that might enhance or detract from their sexual experience. "We talk about preventing pregnancy, we talk about non-contraception benefits like skin clearing up or controlling when and how you get your period, but we don't have a cultural narrative about discussing how contraceptives affect your sexual life," Higgins says.

Regardless of the cause, the lack of counseling might actually undermine the contraception mandate's goals. If a birth control method is causing unpredictable bleeding, weight gain, or a dulled sex drive, women may stop using it entirely. A CDC report released earlier this summer found that among the 45 million women who have used the pill, 30 percent discontinued use because of dissatisfaction with the method-most often because of side effects.

The solution may be to take contraceptive counseling out of doctors' hands. Low notes that nurse-midwives can be a viable alternative to doctors, especially for women who are looking for a more personalized approach. But clinics and private doctors' offices can also cut costs by enlisting non-clinicians to walk women through their contraceptive options. In 2007, three years before the passage of the Affordable Care Act, researchers at Washington University in St. Louis implemented a pilot program called the Contraceptive CHOICE Project. Over the course of four years, the CHOICE Project provided 10,000 St. Louis women with free contraception, with the goal of decreasing unintended pregnancy. Gina Secura, one of the project's directors, said that contraceptive counseling wasn't initially built into their program model. But they quickly realized it was crucial to its success. "We had thought cost was the only barrier," Secura says. "But the majority of women came to us not realizing that there were lots of choices available."

Because funds were limited, Secura and her colleagues recruited research assistants to counsel women about their options. The result was even better than they could have hoped. "Our participants were counseled with their clothes on, with all the methods out for them to see and touch," Secura says. "That lends itself to a much more engaging interaction than sitting at the end of an exam table with a plastic robe on and the doctor in a white coat." Few women ended up choosing the pill. Most went with a long-acting contraceptive method, like an IUD or an implant, and the results were striking. Women who opted for a shorter-term contraceptive like the pill were 20 times more likely to have an unintended pregnancy.

According to Adam Sonfield, a senior public-policy associate at the Guttmacher Institute, a reproductive-issues think tank, many publicly funded clinics have already embraced a similar counseling model. "Trained counselors can spend a lot of time talking to clients without having to worry about the more expensive time that you'd have to bill for a physician," he says. "But you don't really get that in a typical doctor's office visit. Private practices can take some lessons from public-health centers."

Will the Affordable Care Act (ACA) encourage doctors to enlist health educators or counselors to walk women through their options? "It's always slow going, trying to change practices," Sonfield notes. He's hopeful that the ACA will urge doctors to stop thinking about contraception in isolation, as a tool to prevent pregnancy, rather than as a drug that's intimately linked to women's sexual and reproductive lives. But it's still unclear to what extent doctors will be compensated by contraceptive counseling. Insurance companies will need to be proactive, and realize that reimbursing doctors for contraceptive counseling is good for their bottom line. "If they're expecting clients to stay on their insurance plan for a long time, there's no downside to improved contraceptive use," Sonfield says. "It's in insurers' interest to help women think about the kind of birth control that works best for them."