Analysis Contraception

Why ‘Free Birth Control’ Is Not Free

Jodi Jacobson

Many reporters and columnists have consistently used the word "free" when describing the new preventive health- care benefits for women under the Affordable Care Act. While these benefits are critical to women's health, public health, and the economic health of our country, they are not "free."

Yesterday, August 1, 2012, was a momentous day for women, marking the official beginning of a process of ensuring that millions of women across the United States will—finally—have access to a full range of preventive health-care services without a co-pay.

These include a wide range of services and interventions identified by the Institutes of Medicine as essential to women’s health and well-being, including breastfeeding support, supplies, and counseling; screening and counseling for interpersonal and domestic violence; screening for gestational diabetes; DNA testing for high-risk strains of HPV; counseling regarding sexually transmitted infections, including HIV; screening for HIV; contraceptive methods and counseling; and well-woman visits. Likewise, the ACA also ensures that plans must cover an array of services, vaccinations, and interventions, including those specifically needed by women, infants, children, and adolescents at different points in their lifecycle.

Unquestionably, due to the efforts of religious and political fundamentalists at the state and federal level to deny women access to reproductive health care of virtually every kind, the benefit that has gotten the most media attention is the one involving contraception without a co-pay. Many media outlets (see ABC, NBC, Grist, Shape.com) and some columnists, including our colleague Amanda Marcotte, have described the new birth control benefit as making contraception “free,” most frequently, for example, stating that now women will have access to birth control for free.

This is not the case, and it is misleading—and politically dangerous—to say so.

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To get birth control without a co-pay means you have an insurance policy. No one can walk into any pharmacy today and get the pill without a prescription, which in any case first entails a visit to a doctor’s office. No one without insurance can walk into a doctor’s office and get an IUD for for free, nor any kind of contraception, unless they pay out of pocket or meet the means test for and are covered by Medicaid, an increasingly difficult enterprise in itself but the subject of a different article. Ten percent of women in the United States who work full time are currently uninsured and without coverage, they do not have access to “free” birth control. Nor do other women without insurance, or those whose plans are, for logistical reasons or because they were grand-fathered, not yet compliant with the ACA on preventive care. None of these women have “free” birth control now, and they will not later even if they get insurance. (See the National Women’s Law Center Guide on what to do if you have questions about your insurance plan and contraception without co-pay.)

Why? Because if you have insurance, you pay for it, either by virtue of your labor or out of your own pocket, or, depending on the situation, both. And under the ACA, it is now mandated that your insurance plan cover certain benefits without a co-pay. This does not make them “free.” It means that you are paying for that service as part of your premium. You earned it, you paid for it, it is yours. If you pay for it, you deserve to get it.

My first “real job” after college came with health insurance benefits. I worked very hard in that job, and by extension for those benefits. I earned them through my work in the very same way I earned a matching benefit for my retirement account, the vacation time I got, my life and disability insurance, and the Social Security earnings paid to the government. None of these were a gift. I earned them.

Throughout my career, I have been employed in positions where my health insurance was either fully or partially covered by my employer; in the latter case, the employer share was part of my compensation package (and when I was hired, this was explicitly made clear) and I paid a portion of the insurance premium out of my salary. I was fortunate during much of that time in that I also earned generous health benefits for my children. More recently, I was self-employed for three years, and I paid my insurance premiums in full, out of my pocket, at considerable cost. And I earned every single penny I spent on health insurance and therefore every benefit I got from it.

Under the terms of various of my prior health policies, various medical services, such as well-baby and well-child exams, were covered without a co-pay and did not require me to meet a deductible. Other things, such as our endless visits for my kids’ ear infections, laboratory work, dental care, medical tests, and some doctors visits required co-pays, generally in the range of $15.00 to $50.00 a visit for the simple kinds, and more for the more complicated kinds. I was also often required me to meet a deductible before I could be reimbursed for certain other costs. Prescriptions for me and my kids have invariably cost from $5.00 to $50.00 in co-pays, which, though seemingly small amounts, really begin to add up, especially if you have kids or illness or both.

But those well-baby exams were not “free.” I paid for them with my premium. My insurance premium–paid for and earned by me, and pooled with hundreds of thousands or millions of other people–paid to cover those services. This is a basic principle of health economics and comes down to the old adage, “an ounce of prevention is worth a pound of cure.” Insurance companies don’t make huge profits for nothing. They know that offering certain kinds of preventive care and making that care more accessible to more people means that a small investment in the short-term will keep costs lower in the long term. An early abnormal pap smear leading to early treatment is a lot less expensive for them than is treatment for cervical cancer later on (and quite obviously better for the woman in question). An unwanted pregnancy averted through use of contraception is less expensive than an abortion. And so on.

What the Affordable Care Act does is help to begin making our insurance poilcies and premiums more equitable. As Jessica Arons points out in a comprehensive article, fewer working women than working men in this country have employer-based insurance; insurers have historically charged women more than men in a practice known as gender-rating; and for a very long time, women have paid more out-of-pocket for basic preventive health-care services like pap smears and birth control.

The goals of the women’s health provisions in the Affordable Care Act were to begin addressing these disparities, by making women’s access to health care more equitable, and by dramatically reducing the higher costs women pay just because they are women. These changes unquestionably benefit women. But let’s face it, while these are all great things, the reason that lawmakers and insurance companies did this has to do largely with the cost-savings that will be realized: healthier women mean a healthier society and reduced economic and social costs.

Claiming that the services for which women are covered by virtue of their labor and their earnings are “free” feeds into a narrative persistently cultivated by the far right that taxpayers and the government are footing the bill to expand services “for free” to people who did not earn these. It simply is not true.

I fully support expanding government-funded programs to ensure that all women–those living in poverty, low-income women, and the working poor–have access to birth control and other preventive health services, because it makes sense in terms of public health and the economy, and because such access is a basic human right. But people who earn their insurance coverage pay for it, and they deserve the benefit for which they are paying. Moreover, even those who are eligible for government-subsidized access to care—whether reproductive health care or other kinds of care—also are paying at least a share of those costs through their tax contributions. No one is really getting anything here “for free.”

It is notable that the Obama Administration, which has been widely criticized for not doing enough to advertise or explain the many benefits in the Affordable Care Act, does not refer to the birth control benefit as “free contraception.”

Let’s call the birth control benefit what it is: Women’s hard-earned insurance coverage.

It’s ours. We earned it. We pay for it. We deserve it.

News Politics

Missouri ‘Witch Hunt Hearings’ Modeled on Anti-Choice Congressional Crusade

Christine Grimaldi

Missouri state Rep. Stacey Newman (D) said the Missouri General Assembly's "witch hunt hearings" were "closely modeled" on those in the U.S. Congress. Specifically, she drew parallels between Republicans' special investigative bodies—the U.S. House of Representatives’ Select Investigative Panel on Infant Lives and the Missouri Senate’s Committee on the Sanctity of Life.

Congressional Republicans are responsible for perpetuating widely discredited and often inflammatory allegations about fetal tissue and abortion care practices for a year and counting. Their actions may have charted the course for at least one Republican-controlled state legislature to advance an anti-choice agenda based on a fabricated market in aborted “baby body parts.”

“They say that a lot in Missouri,” state Rep. Stacey Newman (D) told Rewire in an interview at the Democratic National Convention last month.

Newman is a longtime abortion rights advocate who proposed legislation that would subject firearms purchases to the same types of restrictions, including mandatory waiting periods, as abortion care.

Newman said the Missouri General Assembly’s “witch hunt hearings” were “closely modeled” on those in the U.S. Congress. Specifically, she drew parallels between Republicans’ special investigative bodies—the U.S. House of Representatives’ Select Investigative Panel on Infant Lives and the Missouri Senate’s Committee on the Sanctity of Life. Both formed last year in response to videos from the anti-choice front group the Center for Medical Progress (CMP) accusing Planned Parenthood of profiting from fetal tissue donations. Both released reports last month condemning the reproductive health-care provider even though Missouri’s attorney general, among officials in 13 states to date, and three congressional investigations all previously found no evidence of wrongdoing.

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Missouri state Sen. Kurt Schaefer (R), the chair of the committee, and his colleagues alleged that the report potentially contradicted the attorney general’s findings. Schaefer’s district includes the University of Missouri, which ended a 26-year relationship with Planned Parenthood as anti-choice state lawmakers ramped up their inquiries in the legislature. Schaefer’s refusal to confront evidence to the contrary aligned with how Newman described his leadership of the committee.

“It was based on what was going on in Congress, but then Kurt Schaefer took it a step further,” Newman said.

As Schaefer waged an ultimately unsuccessful campaign in the Missouri Republican attorney general primary, the once moderate Republican “felt he needed to jump on the extreme [anti-choice] bandwagon,” she said.

Schaefer in April sought to punish the head of Planned Parenthood’s St. Louis affiliate with fines and jail time for protecting patient documents he had subpoenaed. The state senate suspended contempt proceedings against Mary Kogut, the CEO of Planned Parenthood of St. Louis Region and Southwest Missouri, reaching an agreement before the end of the month, according to news reports.

Newman speculated that Schaefer’s threats thwarted an omnibus abortion bill (HB 1953, SB 644) from proceeding before the end of the 2016 legislative session in May, despite Republican majorities in the Missouri house and senate.

“I think it was part of the compromise that they came up with Planned Parenthood, when they realized their backs [were] against the wall, because she was not, obviously, going to illegally turn over medical records.” Newman said of her Republican colleagues.

Republicans on the select panel in Washington have frequently made similar complaints, and threats, in their pursuit of subpoenas.

Rep. Marsha Blackburn (R-TN), the chair of the select panel, in May pledged “to pursue all means necessary” to obtain documents from the tissue procurement company targeted in the CMP videos. In June, she told a conservative crowd at the faith-based Road to Majority conference that she planned to start contempt of Congress proceedings after little cooperation from “middle men” and their suppliers—“big abortion.” By July, Blackburn seemingly walked back that pledge in front of reporters at a press conference where she unveiled the select panel’s interim report.

The investigations share another common denominator: a lack of transparency about how much money they have cost taxpayers.

“The excuse that’s come back from leadership, both [in the] House and the Senate, is that not everybody has turned in their expense reports,” Newman said. Republicans have used “every stalling tactic” to rebuff inquiries from her and reporters in the state, she said.

Congressional Republicans with varying degrees of oversight over the select panel—Blackburn, House Speaker Paul Ryan (WI), and House Energy and Commerce Committee Chair Fred Upton (MI)—all declined to answer Rewire’s funding questions. Rewire confirmed with a high-ranking GOP aide that Republicans budgeted $1.2 million for the investigation through the end of the year.

Blackburn is expected to resume the panel’s activities after Congress returns from recess in early September. Schaeffer and his fellow Republicans on the committee indicated in their report that an investigation could continue in the 2017 legislative session, which begins in January.

Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.

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