Elizabeth Nolan Brown // Blog

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Posts Tagged ‘health policy

If Free Birth Control Lowers Costs, Why Haven’t Insurers Made Birth Control Free Already?

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That’s a question I’ve seen a few places, and which Conor Friedersdorf posed to me last week in  a bloggingheads dialogue. At the time I didn’t have an answer. I knew that birch control coverage could save money and I had some facts and figures about it. But if it drove down costs, why didn’t insurers already subsidize contraception?

One commenter at bloggingheads described my position as “let’s subsidize everything less dumb than the dumbest thing we subsidize,” which I liked. The fact that contraceptive services benefit more individuals or could drive down costs more (in terms of pregnancies prevented) than some of the other preventative services that are free under the new healthcare mandate was my rationale for including birth control (I’m a realist; my view is generally if this mandate exists—and it does—then what makes the most sense under it?) But dumb isn’t really the criteria, I don’t think. More like, “Let’s subsidize everything that genuinely is a preventative service and also benefits a large swath of the American public if we’re going to subsidize other less commonly-utilized stuff. I could be convinced to take dumb stuff off the preventative services list. I’m not sure I support the preventative services mandate to begin with. But since that’s happening: Hell, yes, contraceptive services should be part of it.

Much is made of why totally free versus must-be-covered by insurers, but with a copay. The argument is why should middle- or upper-class women have birth control totally subsidized? The assumption being, of course, that ‘birth control’ means the pill, which generally costs between $4 and $30 a month for a copay, with standard employer-based health insurance.

But the free preventative ‘contraceptive services’ could also include more expensive, longer-form birth control options. The IUD lasts between 5-12 years, and is a great option for young women who don’t want kids for some time or women who’ve already had kids but are pre-menopausal. Insurers have been slow to start covering it, and it’s expensive without coverage (between $500 and $1,000, for the IUD and insertion). That’s actually quite cost-effective in the long-run: At $1,000, spread over 5 years, it would only amount to about $16 a month—right around the average monthly oral contraceptive copay. But $1,000 is a lot of upfront cost, and that’s a big reason why women don’t choose this very effective birth control option.

Another very effective birth control option? Sterilization. It costs quite a lot up front if not covered by insurance. Which means it also costs quite a bit up front for the insurance company who’d have to subsidize it. But a woman who has her tubes tied or a man who has a vasectomy can cost less over a lifespan, because they’re not using birth control monthly and they wont’ get pregnant and need pre-natal and maternity care or an abortion. [And these are just the health care costs saved; less unwanted pregnancies brings less poverty, less unwanted societal costs, etc.]

So if this is all such a great deal for insurers, why haven’t they done it already?

Here’s my stab at a theory. The reason insurers haven’t already started offering free contraceptive services, if this drive down costs, is because with employer-based healthcare and folks jumping jobs so much these days, most people only have the same insurance company or plan for a few years. Subsidizing contraceptive services might drive down costs for you (relative to pregnancy or abortion), and in doing so drive down overall health care expenses in this country. It could drive down social costs. But it’s unlikely to substantially improve the bottom line of any particular health insurance company.

Of course, with the way the insurance market works, wouldn’t any given plan be just as likely to have people currently using free contraceptive services, thus driving up costs, and people who’d already benefited from contraceptive services, thus driving down costs? I don’t know. I’m not terribly well-versed in the economics of insurance policies and risk pooling. Maybe any particular insurance company is likely to have a net draw in costs expended and saved by offering free birth control services.

There may be a simpler reason why insurance companies don’t subsidize birth control: Because it’s the way they’ve always done things. The upfront cost—even just in terms of the time of the people involved in doing it—of changing their policy probably wouldn’t outweigh the savings for a while. Or maybe they just figure that women who use birth control will do so regardless, and they might as well make that $12 co-pay each month from each of them. (The latter theory is maybe true now, but maybe less true once everyone must be insured? And also maybe not as relevant when you, again, consider that birth control doesn’t just mean the pill).

Another component of this I’ve written about recently and Conor and I talked about is the conscience mandate. In any discussion of whether religious employers should have to cover contraceptive services, I feel it’s important to note: People use the pill for things other than pregnancy prevention (thanks, Erin, for reminding me of this). A Guttmacher Institute study found 14% of all birth control users rely on the pill solely for non-contraceptive reasons, such as reducing menstrual pain, treating acne or trying to tame irregular periods.

Churches are already exempt from the contraception mandate, but religious employers—like hospitals and universities—want to be able to (and can, now) opt out of covering contraception. And everyone’s framing it like a matter of choice—well, you choose to go to a religious school, or you choose to work for a religiously-affiliated employer. If covered/free contraption was so important to you, you could choose to go to school or work elsewhere (nevermind for now that just going to work elsewhere sometimes really isn’t that simple).

But I think framing it in terms of individual choice is a bad idea; it’s about whether a broad-spectrum of individual employers should be able to opt out of insurance coverage mandates they don’t like. I don’t think they should. Right now, we’re talking contraception, but it opens the door for any employer to opt out any insurance coverage requirements they don’t like.

Please note that this post is less a polemic and more a sort of stream-of-consciousness grappling with thoughts surrounding this issue. It’s a complicated issue. Do share your thoughts with me, too.

Yes, yes, 1,000 times yes.

Of course access to affordable birth control is primarily a woman’s problem, but how many men have not had babies they didn’t want because the women they were sleeping with were on birth control? Contraception is something that benefits both women and men. Phoebe’s totally right that most men don’t have any idea about how birth control works, and it’s just … sad, and stupid. But I am happy to report that I had a lovely discussion about the benefits of IUDs and the drawbacks of the pill with three women and one man at the bar last night. Anyway, I’ll leave you with Phoebe:

Precisely because contraception is oh-so-private, misconceptions arise – especially, needless to say, among men – about what this “birth control” thing is all about. They easily forget that the very need for contraception comes from women having sex with men. Sparing these men – I might add – 18 years of child-support payments, not to mention the serious possibility of 18 years of continued communications with every woman they’ve ever slept with. It becomes a discussion about women choosing to have sex, when the sex in question by definition involves men. Not such an issue for women who have sex with women.


Written by ENB

March 6, 2012 at 7:08 pm

Kansas Lawmakers Think It’s Fine For Doctors To Lie To Patients To Prevent Abortions

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By far the scariest of the anti-abortion bills pending before scores of state legislatures in the U.S. right now is a bill budding in Kansas that would let doctors withhold critical medical info from patients with no consequences. Among the bill’s many provisions is one exempting doctors from malpractice suits if they withhold information—such as potential birth defects or anything else that poses a health risk for the mother or child—in order to prevent an abortion. A suit can only be brought if the mother dies.

The bill assumes a doctor’s right not to potentially contribute to someone getting an abortion trumps both his duty to do his job and and a patient’s right to receive full and accurate information from their doctor. It’s also filled with some of the greatest hits of other states’ anti-abortion efforts: A requirement that a pregnant woman listen to a fetal heartbeat before abortion; doing away with tax credits for abortion providers; and stopping tax deductions for health savings accounts that include abortion coverage. It would also require doctors to tell pregnant women that abortion will increase their risk of breast cancer—a theory that’s generally disputed by doctors, scientists and health groups, including the World Health Organization and the National Cancer Institute. And:

With language stating that anesthesia is administered to fetuses during surgery and indicating that an unborn child feels pain, the Kansas bills calls for making 20 weeks the latest time for having an abortion, a decline from the 21-week point adopted last year. (Rep. Barbara Bollier, a moderate Republican) said she has professional objections to this requirement, saying that medical reports show that a fetus does not feel pain until 25 to 30 weeks and that the anesthesia is administered to prevent a rapid fetal heartbeat, which she said arises as a reflex to external stimulation.

Republican Gov. Sam Brownback said last week that he’s likely to sign the bill if it comes before him:

Brownback, speaking to The Huffington Post Monday following the National Governors Association meeting, said that while he has not read the 69-page bill, he is likely to sign the proposal since he opposes abortion rights. Brownback, a former U.S. senator, has signed several anti-abortion bills since he took office last year.

“I am pro-life,” Brownback said. “When I campaigned I said that if a pro-life bill got to my desk, I will sign it. I am not backing away from that.”

The bill, however, has yet to pass out of committee—it’s got a ways to go before getting to Brownback’s desk. Both Kansas’ Senate and House of Representatives are controlled by Republicans, but the more conservative House is expected to approve it, while a more moderate Senate could vote it down. But what a crazy point we’ve come to in all this conscience business when it seems reasonable to anyone that doctors should be allowed to coerce women into giving birth by withholding medical information and only be held accountable for any health problems this leads to if the patient ends up dying.

Image: Statemaster.com.

Written by ENB

March 3, 2012 at 1:14 pm