Where’s the Birth Control?

Sharon Lerner

None of the bills emerging from either the House or the Senate require insurers to cover all of the elements of a basic gynecological "well-woman" visit leaving out essential care such as pelvic exams, STI counseling and - yes - birth control.

Reposted with permission from The Nation.com.

Recently it has seemed healthcare reform may be on the mend. The public option
returned from the brink of death. The town hall fever broke as
inexplicably as it began. And Congress is in the process of remedying discriminatory
insurance-company practices
based on pre-existing conditions and
gender. But just as the prognosis for our healthcare system is beginning
to look sunnier, yet another complication has emerged: so far, reform
legislation has failed to require insurers to cover some basic
preventive services for women, or prevent providers from charging extra
for them.

None of the bills emerging from the House and Senate require insurers to
cover all the elements of a standard gynecological "well visit," leaving
essential care such as pelvic exams, domestic violence screening,
counseling about sexually transmitted diseases, and, perhaps most
startlingly, the provision of birth control off the list of basic
benefits all insurers must cover. Nor are these services protected from
"cost sharing," which means that, depending on what’s in the bill that
emerges from the Senate, and, later, the contents of a final
bill, women could wind up having to pay for some of these services out
of their own pockets. So far, mammograms and Pap tests are covered in
every version of the legislation.

Granted, Congress can’t–and shouldn’t–get into the business of
spelling out every possible cause for a trip to the doctor. No one wants
the process to collapse under a mountain of requests from special
interest groups à la the Clinton mess in 1993. But women, half
of all adult patients, are not a special interest group. And since both
the House and Senate bills include lists of specific services that must
be covered by health insurance companies and be provided without asking
patients for additional money, it’s hard to understand why all the
services provided in a basic well-woman visit to the gynecologist isn’t
on them along with maternity care, newborn care, pediatric dental and
vision services, and substance use disorder services.

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The fault for the initial omission can be laid at the feet of Democrats,
who shied away from the issue, not wanting to invite controversy,
according to women’s health advocates who tried unsuccessfully to get
women’s preventive health care included in the basic benefits package.
Some of the concern had to do with cost. Adding any required service to
the basic benefits package would mean the Congressional Budget Office
would give the bill a higher score, or price tag, leaving it more
vulnerable to attack by budget hawks. But another part of the problem
clearly stems from the fact that women’s bodies have become political
lightening rods, even when abortion is not the issue.

Consider what happened when the subject of women’s preventive healthcare
services came up in the Senate Health, Education, Labor and Pensions
Committee (HELP) in July, after the minimum benefits package had already
been determined. Because some essential care for women wasn’t included
in the list, HELP committee member Senator Barbara Mikulski proposed an
amendment that would require the Health Resources and Services
Administration (HRSA) to stipulate that basic women’s health services
would be covered. The language said nothing about abortion, referring
only to "preventive care and screenings."

Yet the voting on the amendment went exactly along pro- and
lines. The amendment passed by just one vote, with all the committee’s
Republicans as well as Pennsylvania Senator Robert Casey, an
anti-abortion Democrat, voting against it. The committee’s discussion
the amendment was dominated by Republicans’ worry about the possibility
of government money winding up in the hands of Planned Parenthood.
Since there is no similar language included in the just-released House
bill, the only hope for requiring full coverage for these essential
services now lies with the Senate.


While some within the anti-abortion movement have long opposed birth
control, there is still widespread support for it among the general
public, with virtually all women of childbearing age who have had sex
using contraception. So why would senators treat birth control and other
basic women’s health services as a proxy for abortion? "People equate
family planning services with Planned Parenthood, and they equate
Planned Parenthood with abortion," says Adam Sonfield, an expert on
funding for reproductive health services at the Guttmacher Institute.
The senators who turned Mikulski’s language into a referendum on
abortion "either misunderstood or purposely distorted the amendment."

Either way, the irony of letting anti-abortion sentiment undercut the
coverage of birth control is that it will likely lead to more abortions.
"If women can’t get this kind of primary care, there are three clear
outcomes: cancer, abortions and infertility," says Anne Davis, medical
director of Physicians for Reproductive Choice and Health, and a
practicing Ob/Gyn in New York City. Davis cites the facts that untreated
sexually transmitted infections can lead to infertility, and that pelvic
exams help diagnose cervical cancers. As for the importance of
covering–and not requiring women to kick in additional money for–birth
control, Davis says, "It’s fundamental primary preventive care. So if we
don’t do this, we’re causing a lot of abortions."

Still, some Democrats involved in the health reform sausage-making
process counsel patience. Noting that both Pap smears and mammograms
should be covered by a reform bill, Senator Al Franken said, "There’s
more we need to do for women’s health, but this is a huge step forward
for American women, many of whom don’t get these recommended screenings
right now. What we pass may not be perfect, but it will make progress in
improving the lives and health of women."

Yet, before we resign ourselves to a very imperfect health reform bill,
it’s worth reminding lawmakers that women’s health extends far beyond
abortion. And while those who make our laws may fear the consequences of
taking a stand for basic services for this half of the population, the cost
of not doing it, both in terms of health and politics, is sure to be far

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