The burden of contraception falls primarily on women. In the United States, women need prescriptions for the majority of contraceptive methods, and so are vulnerable to changes in the healthcare system affecting access to care. Recently, President Trump has issued executive orders on religious liberty and related subjects that have paved the way for a rule to expand the grounds on which corporations and insurers could claim a moral or religious exemption to providing coverage for contraception.
At the same time, the US Congress is attempting to replace the Affordable Care Act (ACA). One of the act’s provisions, which was near-universally lauded by the public health community, was that insurance companies had to cover preventive care services, including contraception, with no out-of-pocket costs (deductibles, co-payments, or co-insurance). More than 55 million women now have access to birth control without out-of-pocket costs — saving more than $1.4 billion on birth control pills in 2013 alone.
The birth control benefit, as it’s commonly known, has been a boon for many women, but it is unlikely to survive in the replacement plan. Moreover, the Trump administration doesn’t have to wait for new legislation — they can roll back contraception coverage through the rulemaking process. We may see a return to the days when many insurance plans cover Viagra, but not the pill.
How do women access contraception in the current marketplace?
Most post-ACA healthcare plans covered the preventive service of contraception in the majority of its forms, including oral contraceptives and long acting reversible contraceptive methods (LARCs). Most forms of contraception have multiple uses, from treating heavy menstrual flow and cramping to family planning, so their inclusion in healthcare plans is generally seen as a reasonable service.
The notable exception to this rule is religious organizations. Under the Obama Administration, organizations that were primarily religious in nature, such as churches, were not obligated to provide plans covering contraception to their employees if it was against the key tenets of their beliefs. These organizations generally fell under IRS codes for religious organizations and did not comprise a large portion of the employer market.
What are the changes in the new rule?
The new rule, which could become law as soon as it is published in the Federal Register, expands the definition of organizations that exempt themselves from including plans with contraceptive coverage in their catalog of choices for employees. In particular, there is repeated reference to moral conviction and moral objection to contraception, while previous iterations of exclusion criteria primarily focused on non-profit religious organizations.
This means virtually any employer or insurer who had a moral or religious objection to covering contraception could opt out of doing so. While it is not clear what impact this could have, it is not difficult to imagine that this could lead to an increase in employers seeking exemption from covering contraception and family planning services.
This is especially troublesome for many lower-income women, who would further be affected by cuts in several federally funded programs that could subsidize the cost of reproductive healthcare for them, including Title X. While this by no means signals the end of contraceptive care in the United States, it does have the potential to pose an impediment to access. And with proposed budget reductions in Medicaid and TANF, these changes will have the largest impact on women of lower socioeconomic status.
What is the likelihood of this becoming policy, and in effect law?
The rule is still under review by the administration, but it has been fast-tracked in an effort to clear it before opponents gain traction. (Update: Once the draft rule is released, the Trump Administration will accept public comments for 60 days.) If you are concerned about the implications of such a policy, or would like to further engage in dialogue about this topic, it is important to contact your legislators! You can find your House Representatives here and your Senator here.