Harvard Business School Professor of Leadership John Kotter says accelerating change often requires creating and sustaining a sense of urgency. Short-term wins can help to fuel change, but they also can lead to complacency. A premature celebration can result in a loss of momentum.
Contraception reduces unwanted pregnancies. Reducing unwanted pregnancies helps to lower pregnancy- and childbirth-related morbidity and mortality, may help to reduce poverty, and prevents the need for some abortions. Beyond these health and societal benefits, contraception can help couples decide whether and when to have children. One survey reports that nearly all sexually active women in the United States have used at least one form of contraception. Given these important benefits and high demand, one would think that all payers would pay for contraception. Think again.
In July, the departments of Health and Human Services (HHS), Labor, and Treasury issued guidance regarding birth control coverage under the Affordable Care Act (ACA). The related press release quotes HHS Secretary Xavier Becerra as saying “Under the ACA, you have the right to free birth control — no matter what state you live in.” Labor Secretary Marty Walsh added, “Today’s guidance makes clear that the law requires group health plans and health insurance issuers to provide contraceptive coverage — including emergency contraception — at no cost to participants.” Promoting the new guidance was appropriate. However, this celebratory language masks the fact that not everyone has coverage, and ignoring that may lead to complacency. And the self-purported clarity of the guidance may obfuscate the problems.
To help sustain a sense of urgency, let’s clarify who does and does not have birth control coverage under the ACA.
Those covered under the ACA
The ACA requires that most private plans cover preventive services, including prescribed contraceptives, without copayments or other cost sharing. The current requirement is to cover the full range of female-controlled contraceptive methods approved by the FDA, effective family planning practices, and sterilization procedures. Beginning with plan years that start in 2023, the Health Resources and Services Administration (HRSA) will expand covered contraception methods to include all that are FDA-approved, -granted, or -cleared.
Current contraceptive-care coverage requirements include counseling, initiation of contraceptive use, and follow-up care (e.g., management and evaluation, as well as changes to and removal or discontinuation of the contraceptive method). HRSA’s Contraception Guideline for 2023 adds screening, education, and the provision of contraceptives to this list, and expands follow-up care to include the continuation of contraceptives. HRSA develops these guidelines on the basis of recommendations by the Women’s Preventive Services Initiative (WPSI), an expert panel of the American College of Obstetricians and Gynecologists (ACOG).
The term “female-controlled,” found in the current coverage requirements, is missing from the new requirements. Why? The 2023 HRSA guideline recommends all contraceptives listed in the FDA’s Birth Control Guide — which includes condoms and sterilization for men. While WPSI added condoms to its list of covered contraceptive methods for 2023, it interestingly omitted sterilization for men because, as per a footnote in the HRSA guideline, it is beyond WPSI’s scope. That is, however, a bit curious, given how ACOG materials note that sterilization in men is more effective and safer than in women.
Those not covered under the ACA
As mentioned earlier, the ACA requirements apply to most private plans — that is, all except “grandfathered” plans and “objecting organizations.”
Grandfathered plans are those that were in existence before the signing of the ACA on March 23, 2010, and that have not since experienced significant changes to their coverage. While these plans are disappearing through attrition, they still cover many lives. The Kaiser Family Foundation’s 2020 Employer Health Benefits survey estimated that 14% of workers were enrolled in a grandfathered plan.
An objecting organization may object to coverage on the basis of religious beliefs or moral convictions. Supreme Court Justice Ruth Bader Ginsburg’s dissenting opinion in Little Sisters of the Poor Saints Peter and Paul v Pennsylvania et al (2020) cited government estimates that approximately 580,000 women of childbearing age could lose access to no-cost contraceptive services if their employers became eligible for this exemption. It is not clear how many women who get their health insurance through objecting organizations and, thus, have lost their contraception coverage under the ACA.
The ACA requirements do not apply to Medicare. Medicare doesn’t cover birth control — which may not seem shocking, considering that Medicare is typically associated with people aged 65 and older — but about 13% of Medicare beneficiaries are under age 65, including approximately 1 million women of reproductive age (18–44). Though Medicare may cover contraceptive medication and procedures that are medically necessary to treat or manage a condition, the exclusion of birth-control coverage may be important to this younger subset of beneficiaries. And although Medicare Advantage and Part D plans may voluntarily cover contraceptives for birth control, the potential gap, sadly, does not seem to have been quantified.
A renewed sense of urgency
The ACA contraception coverage requirement was a win. The evolving WPSI guidelines for contraception are wins. And the recent guidance by the departments of HHS, Labor, and Treasury was a win. But the Supreme Court’s decision in Little Sisters, which upheld the Trump administration’s contraception coverage exemptions for employers with religious or moral objections, was a loss. And no requirement to cover contraception under grandfathered plans and Medicare are misses.
Let’s size the problem and accurately quantify the millions of women that do not currently have but could benefit from contraception coverage. We need to celebrate the successes and count the losses. It’s too soon to declare victory, as that supports a false sense of security. It’s time for a renewed sense of urgency, courage, and perseverance.
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