Birth control has been long applauded as one of the biggest public health advancements of our time. According to the Guttmacher Institute, over 99% of sexually active women ages 15–44 have used at least one contraceptive method in their lifetime.
So, why, 60 years after the first FDA-approved oral contraceptive, is it still treated as nonessential in our healthcare system? And, more importantly, what can be done to rectify this?
Benefits of Birth Control
While contraceptives are frequently prescribed to help manage conditions like polycystic ovary syndrome (PCOS) and endometriosis, their primary purpose is to prevent pregnancy. In addition to being a major life milestone, pregnancy and childbirth are extremely significant health events even if everything goes according to plan. Reductions in unplanned pregnancies associated with birth control is directly tied to better health outcomes for mothers and children, making birth control an essential part of preventative healthcare.
Fiscally, accessible, and affordable — ideally, free — contraception is a no-brainer. It is estimated that every $1 invested in family planning programs, including contraceptive care, saves federal and state governments approximately $7 due to decreased rates of unintended pregnancies.
Birth control access plays a large role in increased education and economic success, as it provides individuals with more control over when and if they choose to have children. Contraception has also been credited for improvements in the number of women completing college, increased numbers of women-owned companies, and narrowing of the still too large gender pay gap.
With the growing evidence around the benefits and effectiveness of contraception, the U.S. should be seeing increased access and fewer barriers. Instead, we are seeing more unnecessary policies put into place that ignore good public health practices and expert recommendations. This backward trend is alarming to healthcare advocates as it actively prevents individuals from receiving medical care that is essential to their health and well-being.
Federal policy provides employers with an exemption to the Affordable Care Act’s (ACA) contraceptive coverage mandate, allowing them to refuse the coverage of birth control under their employer-sponsored insurance if doing so violates their religious beliefs. The U.S. Supreme Court recently expanded criteria for employers who can be exempt from the ACA contraceptive mandate to include the employer’s “morality.” This ruling also made the process for an accommodation to the mandate, which allowed individuals whose employers have religious objections to still receive coverage for contraceptives, optional instead of mandatory. These decisions created even more barriers to contraceptive coverage — making services already difficult to access out of reach for more individuals based on their employer’s beliefs, not on what is medically appropriate.
Contraceptive coverage provides much-needed, and often time-sensitive services — and many states fail to address that in policy and practice.
Many state policies about contraceptive care ignore recommendations from respected healthcare experts and organizations. Even more progressive states such as New Jersey do not adhere to guidance from the CDC, which recommends individuals are provided with 12 months of their chosen contraceptive method at a time. When extended dispensing occurs, individuals are less likely to have gaps in their contraceptive use that can result in unintended pregnancy because they faced difficulties (such as time off work, childcare, and transportation) to attend an appointment that is not medically necessary. Instead, states restrict how many months a contraceptive can be dispensed before a new prescription is needed, which can result in a lapse of coverage.
States also often fail to take the necessary steps to not just provide contraceptive coverage on paper but to truly ensure that these services are accessible for all. Over 19 million women in the U.S. who are of reproductive age live in contraception deserts — which is a county with no reasonable access to a health center that offers all contraceptive methods. This means that even getting an appointment where an individual can access all forms of birth control can be incredibly difficult. A lack of state incentives to provide the full range of contraceptive care, specifically low reimbursement rates for these services, play a direct role in this access barrier.
COVID-19 and Contraceptive Care
In a time where efforts were made across the country to ensure individuals could still receive healthcare while maintaining safe social distancing during the COVID-19 pandemic, contraceptive care continued to face additional hurdles — the impact of which we are already seeing.
Some states were proactive about this. For example, New Jersey Governor Phil Murphy appropriately called out family planning services as healthcare that should continue during the COVID-19 pandemic. However, many states used the pandemic as a pretext to further limit access to reproductive health services, including contraceptives and abortion.
Additionally, many individuals put off reproductive healthcare during the early months of the COVID-19 outbreak. A recent report from Guttmacher Institute reported that 1 in 3 women either canceled or delayed a reproductive health appointment or had trouble accessing their birth control due to the pandemic — and those numbers were higher for Black, Hispanic, and low-income women.
As these patients begin to utilize the healthcare system for their contraceptive care again, the need for policy change is heightened, especially as more individuals face cost concerns about contraception due to changes in both employment and insurance coverage.
Call to Action
On a federal level, we need to stop treating birth control as different from all other healthcare services. We need to put a patient’s health, needs, and autonomy at the center. Most notably, this means that exemptions to the ACA contraceptive mandate should not impact an individual’s access and coverage of these services.
For states, the focus should be to not only improve contraceptive coverage but to also advance meaningful access to services. States cannot assume that bare minimum coverage for birth control will mean all populations can obtain the contraceptive they need. They must reform systems where continuous contraceptive access is unnecessarily difficult for those with limited resources. Policy changes — such as extended supplies of oral contraceptives and processes to ensure the full range of contraceptive options are available throughout a state — are a step in the right direction.
Finally, these changes cannot be maximized without a workforce of healthcare providers who are given the education and tools to support quality and comprehensive care delivery. That is why earlier this year, the New Jersey Health Care Quality Institute created the Reproductive Health Access Project Provider Access Commitment Toolkit (NJ-RHAP PACT) to help educate providers and advocates about best practices for contraceptive care.
There is no reason for individuals across our country to face so many hurdles to accessing services that are safe, effective, and essential to their health.
Birth control is healthcare – it’s time we treat it that way.
Brittany Stapelfeld Lee, MSW, is a policy associate at the New Jersey Health Care Quality Institute where she manages the New Jersey Reproductive Health Access Project (NJ-RHAP).