Take a Pill

The U.S. Department of Health and Human Services caused quite a stir recently when it made final a rule requiring private insurance plans to cover basic preventive services without an additional co-pay or deductible starting in 2012.

Why all the fuss? Among those preventive services -- which include activities such as screening for gestational diabetes, breastfeeding support, and annual well-woman visits -- is access to contraception. And while the rule exempts religious organizations (like, say, the Catholic church), many religiously-affiliated institutions that offer health insurance (like, perhaps, your local hospital or, in my backyard, Georgetown University) must comply. Those who want to cut past the spin can read the rule -- including the test for whether an organization qualifies for the religious exemption -- here.

The predictable media tempest followed. I don't think I saw a headline that actually said, "Obama Administration chooses free love over religion!" but some of the coverage came close.

Let's all step back and take a deep breath.

For starters, none of these services is "free." Employers -- and, increasingly, individuals -- pay a good deal for health insurance coverage each month. These are simply benefits that you are paying for "up front" with your premium; you can't be charged an additional co-pay, co-insurance or deductible.

This change, brought to us by the Affordable Care Act, is great news for everyone with private health insurance. Respected health professionals -- not the federal government -- spent months reviewing data and running cost-benefit analyses before recommending certain preventive services to HHS for full, co-pay-free coverage.

The final list of services that must be covered without an additional charge is available here and includes vaccinations, cancer and disease screenings for patients with a higher risk profile, and counseling on issues such as domestic violence, obesity, and depression.

The point of removing financial barriers to these services is twofold. First, a number of studies have found that even small costs can discourage action. Second, the benefits of these services -- in terms of improved health, reduced risk of disease, lowered long-term health costs, and safer and stronger communities and families -- outweigh their costs.

So how did contraception end up on this list?

First, family planning improves the health outcomes for both mother and child. For example, the American College of Obstetricians and Gynecologists (ACOG) notes that women who become pregnant less than six months after their previous pregnancy are 70 percent more likely to have membranes rupture prematurely and are at significantly higher risk of other complications. These complications extend to the child and include low birth weight, higher incidents of infant mortality and premature birth.

Second, contraception can prevent complications from existing conditions. Every major medical association and the CDC's Healthy People 2020 recommend contraception as a standard of care for women with chronic diseases. Unplanned pregnancy can significantly worsen the health of a woman being treated for diabetes, epilepsy, depression, lupus or some forms of cardiovascular disease. If she does want to have children, timing the pregnancy with the help of contraception is essential because the drug course treatments for some conditions (or even, as with the case of Acutane, for severe acne) may cause severe fetal impairments.

Third, birth control lowers long-term health costs. Last year the Guttmacher Institute analyzed public insurance programs and determined that, conservatively estimated, unintended pregnancies cost tax payers $11.1 billion in 2006. Another Guttmacher study, discussed here, found that every dollar invested by the government for contraception saves $3.74 in Medicaid expenditures for care related to births from unintended pregnancies. Complaints that covering birth control will raise costs have simply not been born out. And when costs go down, it is tricky to base your argument on a "you-can't-make-me-pay-for-X" rationale.

These reports only looked at costs related to births from unintended pregnancies. An additional savings from contraception that everyone can support comes from a reduction in the number women who need abortions. Today approximately half of the pregnancies in the United States are unintentional; of those, about 40% are terminated, or more than a million a year. Just imagine if women could prevent unintended pregnancies. And in fact, studies in the U.S. and other countries show that abortion rates fall as more women use birth control.

Finally, contraceptive use leads to stronger and safer communities and families. Women with unintended pregnancies are less likely to seek adequate prenatal care, less likely to breast feed, and more likely to suffer from depression. Unintended pregnancies are also linked to higher divorce rates and to lower rates of educational and professional attainment by women.

Given this, it is hardly surprising that the U.S. Conference of Bishops was unable to convince the Obama Administration to substitute its beliefs for actual medical standards at religiously-affiliated institutions. (The Conference has a bigger problem than its inability to sway the Administration on this question; 98 percent of sexually active Catholic women report having used contraceptives.)

I understand the political decision HHS made to exempt religious employers from the contraception requirement, but I don't agree the church should trump science when lives are on the line. Religious beliefs are varied and personal. If the religious employer exemption is taken to an extreme, employers would be able to exclude coverage for a variety of accepted medical procedures, such as blood transfusions or HIV treatment.

At the end of the day, each woman has to be able to make these health-related decisions for herself. It is not her employer, but her own sense of morality and the counsel of her doctor that must guide her choices.