During the fight over the passage of the Affordable Care Act (ACA), it was common to hear left-leaning critics grouse that the bill wasn’t strong or comprehensive enough. Defenders of the ACA, myself included, would generally respond to this by pointing out that it’s easier to build on legislation that’s already in place than to build a whole new system from scratch. While there are still legal challenges to overcome, the implementation of the ACA has been getting smoother and more responsive over time. However, there’s still a lot more work to be done. The issue of contraception perfectly illustrates how far we’ve come when it comes to improving health-care access—and how far we have to go.
Even though the birth control benefit, which requires health-care plans to cover 18 forms of contraception without a co-pay, has been subject to the most political controversy of any aspect of the ACA, the Obama administration hasn’t given up or rolled over in the face of anti-choice forces. On the contrary, the White House’s recent actions show that the administration is very serious about implementing the benefit thoroughly.
Just last month, the Kaiser Family Foundation released a report showing that many insurers are trying to weasel out of covering contraception as fully as they should, usually by over-interpreting their legal right to “reasonable medical management.” By doing this, they’ve pushed women away from birth control forms like the ring or the implant, and onto cheaper, but often harder-to-manage, methods like the pill.
The administration responded, by bureaucracy standards, with lightning-fast reflexes. The Department of Health and Human Services (HHS) revised and clarified the regulations, sending out a letter explaining the changes less than a month after the Kaiser report came out. This letter tightened the definition of “reasonable medical management,” explicitly stating that insurers had to cover at least one kind of each type of birth control. It also demanded that insurers make it easier for patients to get a waiver to get their birth control of choice, if their doctor said it was the best option for them.
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It’s great to see the existing system being improved in this way. This week there were a couple of strong reminders, though, that there are huge obstacles to getting contraception that the current ACA doesn’t address at all. As Andrea Grimes at Rewire reported Tuesday, a new study out of the University of Texas’ Texas Policy Evaluation Project (TxPEP) demonstrated that there are many significant hurdles for women who want contraception coverage, whether they’re privately insured, uninsured, or covered through public insurance.
TxPEP interviewed a diverse group of Texas women and found over half of them reported at least one barrier to getting the contraception they wanted. Being unable to pay for services was by far the biggest obstacle. As Grimes explained, many of these women said their insurance would not cover it—even though it really should—showing how necessary the White House’s intervention really is. It also shows that we still need family planning clinics like Planned Parenthood that offer affordable services, because there remain huge gaps in coverage even with insurance. But these are exactly the kind of problems our current infrastructure can be tweaked to fix: tighter regulation of the insurance industry through the ACA, and more money for family planning (though the Texas legislature is doing everything they can to block that).
TxPEP found, however, that there were access issues falling well out of the purview of current legislation. Women reported that they had issues with their health-care providers, that they didn’t have transportation or child care, and that they couldn’t take time off work to get to the doctor in the first place.
And increasingly, women have something else to worry about even if they can make time to get to the doctor: What if, after all the hassle of getting there, the doctor won’t—or can’t—give you birth control? Patricia Miller of Salon reports that the Catholic Church is getting really aggressive about trying to cut women’s access to birth control off at the source, the doctor’s office. “Driven by health-care economics and incentives in the Affordable Care Act, health systems, which are a collection of hospitals and ancillary services, are acquiring physician practices at an unprecedented rate,” Miller writes. The problem? Eight out of ten of the largest nonprofit health systems in the country are Catholic organizations, and they are ready to throw their power around in order to stop you from getting birth control.
In theory, having health systems buy up clinics isn’t necessarily bad. Having someone else in charge of the business side of medicine can free doctors who previously would have had to start private practices up so they can instead focus on patients. But in practice, many of these Catholic health systems are telling doctors they have to follow the ridiculous Ethical & Religious Directives for Catholic Health Care Services, which means, in order to keep their jobs, they have to stop prescribing birth control. Even if they have no problem whatsoever with birth control and have been prescribing it for years. Even if it means regular patients, who have come to trust their doctors, now are being cut off from the contraceptive methods they’ve always used.
The ACA helped create the problem, but there’s nothing in the current version of the law that the HHS could use to fix it. However, Congress can address this problem through separate legislation that puts hard limits on how much health-care systems can interfere with a doctor’s judgment on the best course of care.
In a sense, this was all predictable. As women’s access to birth control increases, it follows that the religious right would panic and try to find back-door methods to take it away anyway. But these assaults on contraception access, along with research showing the practical limitations that keep women from getting birth control, reveal that it’s time for some creative thinking about how to make sure everyone who wants contraception gets the method that’s right for her.
On this week’s Reality Cast podcast, Heather Boonstra from the Guttmacher Institutes recommends using school-based health centers for this purpose. It’s that kind of strategizing that we need to help get around both the practical obstacles and interference by the religious right that is preventing women from getting the care they want. Now that we have a system in place to start addressing all the holes in insurance coverage, it’s time to look to the future and start asking about making contraception not just affordable, but easy.