The Pump Handle

This post is part of the Birth Control Blog Carnival put on by the National Women’s Law Center.

Yesterday I wrote about new Institute of Medicine recommendations regarding preventive health services for women that should be covered by all new health plans without requiring cost-sharing. One of the IOM’s recommendations was that all FDA-approved contraceptive methods be available free of charge to women with reproductive capacity, and this was the one that attracted the most opposition. According to the Guttmacher Institute, 99% of women who’ve had sexual intercourse have used contraception. But a tiny sliver of the public opposes contraception, so that becomes the focal point of reactions to the IOM recommendations.

Here’s what I don’t think most people would argue with: easily accessible, effective contraception, consistently used by women who want to avoid pregnancy, is good for public health. As the Guttmacher Institute explains in its testimony to the IOM, “Contraception helps women avoid unintended pregnancy and improve birthspacing, with substantial, positive consequences for infants, women, families and society.” They also provide details on the cost of contraception, which can be prohibitive for some women, and what research has found about how costs affect contraception decision:

Methods of contraception vary not only in their effectiveness, but also in their costs and the timing of those costs. Condoms are relatively inexpensive on an individual basis, but 50 cents or a dollar per use can add up to substantial amounts of money over a year, much less the 30 years that the typical woman spends trying to avoid pregnancy. Brand-name versions of the pill, patch or ring can cost upwards of $60 per month if paid for entirely out-of-pocket, although generic oral contraceptives can cost considerably less; these methods also require periodic visits to a health care provider, at additional cost. Long-acting or permanent methods, such as the IUD, implant or sterilization, are most effective and cost-effective, but all can entail hundreds of dollars in up-front costs.

For many women, including the 11 million women of reproductive age (15-44) with incomes below the federal poverty level in 2009, these can be daunting expenses. That can be true even for those women with insurance coverage: Average copayments in employer-sponsored insurance have increased considerably over the past decade, to $49 in 2010 for “nonpreferred” brand-name drugs, $28 for preferred drugs and $11 for generics, for plans with a three-tier formulary (the industry standard). With copayments so high, private insurance is in many cases today providing only a marginal discount from what a woman would pay out-of-pocket at a drug store without insurance. In fact, a 2010 study found that privately insured women using oral contraceptives whose plan covered prescription drugs paid half (53%) of the cost of the pills, amounting to $14 per pack, on average. The same study found that the out-of-pocket expenditures for a full year’s worth of pills amounted to 29% of the women’s annual out-of-pocket expenditures for all health services.

… Several studies indicate that costs play a key role in the contraceptive behavior of substantial numbers of U.S. women. A national survey from 2004 of women 18-44 who were using reversible contraception found that one-third of them would switch methods if they did not have to worry about cost; only four in 10 of those women were using a hormonal method or an IUD, and nearly half were relying on condoms. In fact, women citing cost concerns were twice as likely as other women to rely on condoms or less effective methods like withdrawal or periodic abstinence.

… There is evidence that the impact of cost-sharing would specifically apply to contraceptive services and supplies. A recent study looked at the impact of a 2002 change in benefits at Kaiser Permanente Northern California to eliminate cost-sharing for the most effective forms of contraception (IUDs, implants and injectables). It found sizable increases in use of these methods–by 137% for IUDs and 32% for injectables–and a resulting reduction in women’s likelihood of contraceptive failure.

Looking at this and other evidence, the IOM concluded that offering contraceptive services has a large potential impact on health and well-being. Now the Department of Health and Human Services has to decide, based on the IOM’s recommendations, which preventive health services for women it should require new insurance plans to cover without cost-sharing.

This is where there’s room for debate. The vast majority of us can agree that it’s good for women to be able to use contraception consistently when they’re not seeking to get pregnant, but we may not agree on whether insurers should be required to foot the entire bill. And in this case, contraception is the item on the IOM’s recommended list that is most clearly in insurers’ interests to cover. Items like domestic-violence screening and coverage of lactation support and breastfeeding-equipment rental may help reduce health costs in the long run (and are certainly good for overall population health), but there’s a good chance that any long-term savings in healthcare costs will accrue to a different insurer, not the one who paid for preventive services in the first place.

Helping women who want to avoid pregnancy avoid it pays off for insurers very quickly, though. This New England Journal of Medicine editorial compares costs to Medicaid, which in 2008 paid an estimated $257 per client on contraceptive care and an estimated $12,613 per birth (including prenatal care, delivery, post-partum, and first-year infant care). Insurers all negotiate different rates with providers, but if anything that probably means an even bigger gap between the relatively low cost of contraception and the very high cost of births.

HHS needs to consider a multiple factors in deciding which preventive services to require new health plans to cover with cost-sharing for women. Public health is important, but so are insurer costs, which will influence the affordability of health insurance. If insurers have to cover every service that benefits public health, coverage will be out of financial reach for many – and high rates of uninsurance aren’t good for public health, either. Plans that cover contraception are likely to face lower overall costs, though, so it shouldn’t be hard for HHS to see that requiring contraception coverage without cost-sharing will benefit public health without jeopardizing insurance affordability. Eliminating the cost barrier to contraception benefits everyone.

Comments

#1 bob koepp
July 21, 2011

Regarding the cost of contraception, do you ever wonder why the pharmaceutical companies that make chemical contraceptives don’t push the FDA to make their products available “over the counter”, so they could be more easily accessed by women? It’s certainly not about safety, since the most commonly used contraceptive pills are about as safe as aspirin. Call me cynical, but I think it’s all about maintaining profitability. When are people going to wake up to the fact that the medicalization of birth control empowers the medical industrial complex, not women.
#2 Liz Borkowski
July 21, 2011

Bob, I’m guessing you’re talking about birth control pills rather than products like spermicidal gels, which are available over the counter already. I don’t know whether pharmaceutical companies really think that selling a drug by prescription only is more profitable than selling it over the counter, since I would think that making it OTC gives you a much larger pool of potential customers. It’s probably easier to get insurance to pay for a prescription-only drug than for something OTC, though, so maybe drug makers can charge higher prices if the consumers are insulated from the price by their insurance companies.

I don’t know whether an application to sell a birth-control pill over the counter would be likely to get approval from FDA. The agency would likely be pressured to reject the application by those who think it would encourage promiscuity, just as it was pressured to reject the application to sell emergency contraceptive Plan B over the counter. The decision on the medical merits ought to be insulated from FDA’s political considerations, but that wasn’t the case during the Plan B saga. From the drug company standpoint, they would need to factor a lot of PR spending into any decision it might make about requesting that birth control pills be sold OTC.
#3 Art
July 21, 2011

OTC birth control pills would go a long way toward eliminating parental control over daughters by removing logistical, financial, governmental barriers. It makes too much sense. Right up there with making BC free in medical plans. All reasons none of it will happen.
#4 Stevarious
July 21, 2011

The one proven method to bring a country to modern standards is to empower women and give them control over their own biology. It is the one single best thing you can do to help ANY society improve ITSELF.
#5 bob koepp
July 21, 2011

On the other hand…
I think that the de-medicalization of birth control, except when BC is actually medically indicated (a very important qualification), would moot the political debates about covering it in medical insurance plans. That wouldn’t be such a bad thing. The actual production costs for BCPs are minimal. And those of us who want to promote their use could easily support programs to distribute them at no cost to those in need of financial assistance. But there’s a medical-industrial complex, and powerful political interests on both sides of the issue, that get in the way of women controlling their own fertility.
#6 Celeste Monforton
July 21, 2011

Does preventing pregnancies make fiscal sense? Yes.
Are birth control methods cost-effective? Yes.
Will Republicans, who extol the virtues of decisions that are fiscally sound and cost-effective, support HHS if it adopts the IOM’s report? No way.
#7 stripey_cat
July 21, 2011

bob, there are some pretty scary contraindications and potential side effects from hormonal BC. Admittedly, a competent pharmacist could probably screen for them, but many people sadly view OTC medications as not really “real”, and so don’t take the health warnings seriously, or don’t mention them to their doctors when they need other medications. I think you would see a definite rise in mis-prescription, serious side effects, and other complications.
#8 Liz Borkowski
July 21, 2011

Here’s a blog post from Bonnie Rochman at Healthland about the idea of making BCPs available over the counter. One recommendation is that initially only progestin-only pills be offered OTC, because they’re less likely to be contraindicated for the women taking them.
#9 bob koepp
July 21, 2011

I don’t have the statistics on hand, but am informed by European acquaintances that in countries across the pond where BCPs are available OTC, women use them safely, effectively, and responsibly. Presumably, American women could do the same.
#10 Vince whirlwind
July 21, 2011

Women who have medical insurance can afford to have children.

It’s the poor for whom free contraception needs to be made available, especially in places like Sudan where children are dying in their thousands right now due to poor people breeding despite having no food.
#11 Tori
July 22, 2011

@ Vince —

While I certainly acknowledge family planning and health care barriers around the world —

There are probably a number of women who have access to health care insurance as part of their job who cannot afford to have children. I’m one of them. It’s a little revolting that you’d presume to know my financial status or needs.

Additionally, there are women — again, I’m one — who might be financially able to carry a pregnancy to term but for whom this would be a considerable physical health risk. As someone who does not want to be a mother — neither do I want to put my body at risk in opposition to my own life goals.
#12 mio
July 22, 2011

As a pharmacist I’m a little bit leery of making all BC pills OTC. Plan B obviously need to be as when you need it, you can’t be messing around, waiting for dr appointments etc. The efficacy is greatly reduced with time, so a woman in need, need access to it STAT.

But the side-effects and potential complications in use of BC are not trivial, so I think it is a good idea to be in contact with a healthcare provider at least every three years (the longest BC prescriptions in my country).

We have on the other hand great success with allowing midwives and school nurses with special training prescribe BC. We also have a program where the State sponsors a substantial part of the cost for women between 16 and 18, which led to reduced teen pregnancies and abortions. Poor women on welfare may also get help to cover BC costs.
#13 Sharon Astyk
July 22, 2011

Is it in fact the case that BC has *greater* risks of misuse than many OTC medications do? Given the health costs over the years of tampons (TSS), tylenol (liver damage), asprin for children (Rye syndrome), asprin/advil for adults (bleeding)… sleep aids (driving issues, etc…) is it really the case that the risks are unlike any risks we take ordinarily? Free is good, but demedicalized in a society where health insurance is a luxury and doctor’s visits are rare seems valuable as well, and campaigns could be mounted to make people aware of the risks, as they have been with other medications, no?

Sharon Astyk
#14 Jennifer
August 10, 2011

I can’t agree more with this article and some of the comments posted here. It just makes sense for BC to be readily available to women. There are so many factors that prevent women from being able to acquire birth control and if it were available OTC, or in a more accessible way, the number of unplanned pregnancies and disease would definitely reduce. Some women don’t have insurance, or some women come from religious backgrounds and are are told to abstain from sex. When people are taught abstinence-only and there is no other contraceptive knowledge learned, it makes for more unplanned pregnancies. People are going to have sex, it’s nature, there needs to be resources readily available so people can make better decisions for themselves.
#15 Rogue Epidemiologist
August 11, 2011

I’m so close to advocating making Depo-Provera deliverable by blow-darts. But hey, free BCPs is a good start, too.

Have you ever gotten into the heads of people who are wholly opposed to birth control? Read up on the Quiverfull movement. They’re the extreme, but there are mainstream conservatives who share some of their views regarding contraception, and as a voting bloc, they are pretty influential.

btw, if any pills must go OTC, I agree with Liz that it should be a minipills. HOWEVER, they have a greater rate of failure than combination progestin and estradiol. At least the religious right can’t claim they’re abortifacient because the minipills don’t stop ovulation.
If we understand the opposition’s arguments and motivations, we will be better equipped to plan women’s health policies that will hold up to their scrutiny.
#16 Eun Eli
March 23, 2012

abogados de accidentes estamos de acuerdo. Good article.