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Stanford family planning fellow discusses universal contraceptive coverage

Public policy issues related to women's health care have garnered a considerable amount of media attention lately. Carrie Frederick, MD, MPH, who is working in Washington D.C. during her Stanford Family Planning Fellowship, has been in the thick of the national debate. Below she discusses her work with the American College of Obstetricians & Gynecologists on advocating to improve contraception coverage for women.

What main issues have you been working on during your fellowship?

During fellowship, I have been advocating for more universal contraceptive coverage in health plans. By thism I mean ensuring that all women have insurance coverage for all contraceptive methods, without cost-sharing, whenever a contraceptive is requested. Many people are now familiar with the rule that all insurance companies cover contraception with no cost-sharing under the Affordable Care Act. Those provisions will start to take effect in August 2012. However, currently many women either do not have contraceptive coverage in their insurance plan or have to pay significant portions of the expense for their contraception. Other women who are uninsured may only qualify for contraceptive coverage within the first six weeks after a birth.

I am also conducting clinical research to determine the best methods of contraception for women who have had bariatric surgery. We have a lot to learn about how obesity, weight loss, hormonal changes and changes in digestion in these women affect the efficacy of certain methods to prevent unintended pregnancy.

The controversy over one aspect of the Affordable Care Act, whether and when religiously affiliated employers must offer comprehensive contraceptive coverage in their insurance plans, has dominated headlines during your fellowship. What are some of the greatest misconceptions surrounding this component of the health law?

In 2011, the Institute of Medicine (IOM) issued evidence-based recommendations regarding which services should be part of the “essential benefits package” in the Affordable Care Act. The IOM determined that one of the essential benefits was contraception, and in recognition of the enormous personal and public health benefit of family planning, it recommended that the full range of FDA-approved contraceptives be covered with no cost-sharing.

The U.S. Department of Health and Human Services accepted the IOM’s recommendation, and required that under the ACA all insurance companies provide full contraceptive coverage with no cost-sharing, but allowed a narrow exemption for churches and other religious charities if they had moral objections to contraception. The U.S. Conference of Catholic Bishops requested a broader exemption that would apply to religiously-affiliated employers like hospitals and schools. The Obama administration declined to broaden the exemption, and instead determined that if a religiously affiliated employer had an objection, the insurance company itself would directly provide contraceptive coverage to the insured.

The controversy has been centered around the idea of “religious freedom” and whose freedom is more important: that of the employer, or the employee. The fact is that over 99 percent of women use contraception at some point in their life, and 98 percent of Catholic women have used contraception. Religiously affiliated hospitals and schools employ millions of women in the United States, so if they were permitted to exclude this coverage from their insurance plans, many women would have to either pay out-of-pocket or go elsewhere for their contraception.

Twenty-eight states, including California, already have laws requiring private insurance plans to cover prescription birth control. Why is it important that health insurance companies be required to cover FDA approved birth control methods at the federal level?

This is a complicated issue that has to do with insurance law. I am not an expert in the law, but I will try to summarize it. States are free to set their own rules about insurance coverage, thus the current heterogeneity in contraceptive coverage among states. Employers in a particular state who provide insurance for their employees are bound by their own state law, with the exception that employers who “self-insure” are exempt from state insurance law, but not from federal insurance laws.

The Affordable Care Act is a piece of federal health care legislation that leaves a significant amount of flexibility to the states to determine how to set policy in their own state. The idea of the Essential Benefits Package, however, is that insurance plans in every state must cover a certain minimum of diagnostic, therapeutic and preventive health services and products, in the interest of maximizing health for all Americans. Contraceptive coverage was included in the EBP in recognition of the role contraception plays in ensuring health not just for women but also for their children and families.

While in Washington D.C., you've also been involved with advocacy efforts aimed at providing health insurance coverage for immediate, postpartum intrauterine contraceptive device. Why is it important that health insurance companies to cover this method of contraception?

Traditionally, if a woman wants an intrauterine contraceptive device (IUD) after a pregnancy, it has been placed at the routine post-partum visit, around four to six weeks after the pregnancy. In the developing world, it has become popular practice to place an IUD at the time of delivery, recognizing that several factors are in play at that time: 1) the woman is motivated to initiate contraception, 2) it is a convenient time for the provider and the woman, and 3) the cervix is already open, making insertion easy. The downside is that there is a slightly higher possibility that the IUD will come out if placed immediately post-partum, because the uterus is bigger than in the non-pregnant state, and the cervix is open. Approximately 35 percent of women do not return for their postpartum visit, and one study found that of women who desired an IUD, only 60 percent of them got it at their postpartum visit, according to a 2005 study. So by deferring IUD placement to the postpartum visit, an important opportunity to provide reliable contraception may be missed.

The issue that we’ve been trying to address is this: generally, insurance companies (both public and private) pay a pre-negotiated global fee for a pregnancy that includes prenatal care, delivery and postpartum care. If additional services are provided during pregnancy or at the time of delivery, oftentimes they aren’t reimbursed, because of the pre-negotiated global fee. Most insurance companies do reimburse for an IUD placed at the post-partum visit, but have not been reimbursing if the IUD is placed in the hospital when a woman delivers. Thus, many providers are deterred from offering immediate post-partum IUD because the device is expensive, and it’s a financial loss for them or their hospital. We are trying to get insurers to reimburse for the IUD if it’s placed in the hospital, just as they would at the post-partum visit, so that women have access to this important method of contraception if they want it.

You’ve also been advocating on behalf of the American College of Obstetricians & Gynecologists (ACOG) against the Blunt Amendment. Can you explain this piece of legislation and why the ACOG is asking members of Congress to vote against it?

The Blunt Amendment was an extremely political piece of legislation intended to take the religious exemption to the contraceptive coverage mandate much, much further. It was effectively rejected by the Senate on March 1, but it would have allowed any employer to refuse to provide insurance coverage for any health benefit to which it had a religious or moral objection. It was targeted at contraceptive coverage, and the misperception that certain kinds of contraception cause abortion. But it could have been interpreted in such a way that an employer could refuse coverage for blood transfusions if he or she was a Jehovah’s Witness. Or, an employer whose religious beliefs included the misinformation that vaccines cause autism could in theory refuse coverage for vaccines, etc.

We argued against it because we feel that coverage for contraception is important for the health of women and their families, and decisions about health care should not be left to a person’s employer. Unfortunately this is probably not the last we have seen of this sort of legislation.

Previously: A look at the federal mandate to cover contraceptives, Government advisors call for free contraception for women, Another birth control revolution? New health law could provide free contraceptives to women and Women’s health groups launch campaign for no-cost prescription birth control
Photo by Sarah C

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