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OB/GYN Editorial March 2002
Fair Access to Contraception—Legislation
Worth Supporting
Andrew M. Kaunitz, MD
In 1994, research published by the Alan Guttmacher Institute found
that private insurance in the US failed to adequately cover reversible
contraception. Although virtually all indemnity plans covered prescription
drugs, half covered no prescription contraception. Only one third
covered oral contraceptives, and only 15% covered each of the most
common reversible methods (the pill, the copper IUD, Depo-Provera
and the diaphragm). Although HMOs offer somewhat better contraceptive
coverage, less than half cover the four methods indicated above.
In contrast, almost 90% of private insurance plans cover tubal sterilization,
and about two thirds cover induced abortion.
Inadequate contraceptive coverage has important negative implications
for our patients and society. Financial concerns may cause women
to forgo use of any contraception, or choose a less effective method
strictly for reasons of short-term cost. The result? High rates
of unintended pregnancy (one half of all pregnancies in our patients)
and abortion. Of all developed Western countries, the United States
regrettably leads in rates of unintended pregnancy and abortion.
Unintended pregnancy is associated with higher perinatal and maternal
mortality, and contributes to poverty. In addition, women of reproductive
age end up paying almost 70% more in out-of-pocket health care costs
than do men of the same age, with reproductive-related expenditures
accounting for much of this difference. A multipronged strategy
to expand contraceptive coverage is needed.
In 1997, legislation was introduced in Congress to address contraceptive
coverage. The Equity in Prescription Insurance and Contraceptive
Coverage Act (EPICC) would require health plans that provide prescription
drug coverage to provide similar coverage for FDA-approved prescription
contraceptives. EPICC does not require coverage of medical or surgical
abortion. Recent polls indicate that more than three quarters of
Americans support the requirement that health plans cover prescription
contraception.
Since 1998, Congress has required plans participating in the Federal
Employees Health Benefits Program, which covers more than one million
reproductive-age women, to cover all prescription contraceptives.
Of note, this coverage has not resulted in cost or premium increases,
confirming published analyses that use of effective contraception
reduces overall health care costs (J Trussell, et al. Am J Public
Health 1995; 85: 494-503; RT Burkman, FA Sonnenberg. Obstet Gynecol
Clin N Am (December) 2000;27: 917-931). Eighteen states have enacted
laws to require that health plans that cover prescription drugs
also cover contraceptives (Table 1). Contraceptive equity bills
are pending in fifteen states (Table 2). However, most women residing
in states that have not enacted this legislation, as well as those
who work for employers that self-insure, will continue to lack adequate
contraceptive coverage. This points out the need for federal legislation.
 
In June of last year, the US District Court for Western Washington
State ruled that an employer's failure to cover contraception in
its otherwise comprehensive prescription plan constituted gender
discrimination, a decision that adds momentum to contraceptive equity
legislation.
The last 2 years have witnessed the advent of new prescription
contraceptives, including the combination monthly injectable (Lunelle),
the levonorgestrel-releasing IUD (Mirena), the combination contraceptive
vaginal ring (NuvaRing) and the combination transdermal contraceptive
patch (Ortho Evra). However, the lack of consistent health plan
coverage means that our patients, too, often lack access to these
new convenient, safe, and highly effective contraceptive options,
or to existing safe and highly effective methods such as oral contraceptives,
Depo-Provera or the Copper IUD.
The American College of Obstetricians and Gynecologists (ACOG)
has taken a proactive stance in its support of EPICC. In September
2001, Congressional hearings were held to refocus attention on this
issue. Dr. Anita Nelson, who serves on the Editorial Board of The
Female Patient, testified at these hearings. ACOG fellows who wish
to learn more about the status of legislation at the State or Federal
level can contact ACOG's Department of Government Relations and
Outreach (www.acog.org). Many other web-based resources (Table 3)
are available to clinicians who would like to play a positive role
in promoting contraceptive parity legislation. We have the knowledge
and the methods to help our patients avoid unintended pregnancies.
Passage and state by state implementation of EPICC will bring our
patients the means to do so.
Andrew M. Kaunitz, MD
Associate Editor
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