The Patient Protection and Affordable Care Act (PPACA) calls for the coverage of preventive health services. In August 2011 the Department of Health and Human Services proposed a rule that endorsed no cost preventive health services for women based on recommendations by the Inst. of medicine (Inst. of medicine, 2011). Contraception was included as part of the rule (HRSA, 2011).
Contraception has a controversial past. The goal of contraception is prevention of unwanted or unplanned pregnancies. Contraception services as an insurance benefit was first offered by the International Workers Order(IWO) in 1936 (Temkin, 2007). Access to contraception for people was actually illegal in several states. The Supreme Court with the Griswold vs. Connecticut decision (1965) overturned the statutory prohibition against contraception in the state of Connecticut. With Griswold the Supreme Court established a right to privacy. Contraceptives became widely available for the populace at large. Insurance companies did not always include coverage for contraceptive services.
Contraceptive equity is the concept that contraception is a form of primary health care that should be a shared responsibility as part of health insurance. It was common in the late 1990s for insurance plans to cover treatment for male erectile dysfunction . However, coverage was not extended to include birth control for women. Most common form of contraception for women was the oral contraceptive pill at 28% of users. (Guttmacher 2011). Contraceptive availability was challenged as recently as November 2011 in the state of Mississippi with initiative 26. This initiative attempted to define life as beginning at conception. Some advocates of the initiative viewed oral contraceptive pills as a form of abortion.
The United States has a very high rate of unplanned pregnancy. There are nearly 3,000,000 unplanned pregnancies in the United States each year. 49% of pregnancies are unplanned in the United States. Half of these pregnancies or 1.2 million end in abortion. (Guttmacher, 2011). Abortion or the termination of pregnancy is controversial. Access to contraception should not be controversial as it prevents the need for elective abortion.
Plan B also known as “the morning after pill” is a form of emergent contraception. FDA initially approved Plan B as an OTC drug for women over age 18 in 2006 (Tumino v. Torti 2009). Objections were raised about Plan B encouraging adolescent sexual behaviors ( Krishnamurti, Eggers and Fischoff, 2008) and that Plan B caused abortions. (Davidoff and Trussel, 2006). Krishnamurti et al found that plan B did not impact teen decisions to have sex. Plan B does not prevent implantation of fertilized ovum (Davidoff and Trussel, 2006). The Obama administration recently ignored the science through overruling FDA recommendations to make plan B available regardless of age (Edney and Armstrong, 2011).
There are competing ethical demands with contraception. Women as individuals should have the right to control their fertility. This is based within the ethical principles of autonomy and justice based within the ethical theory of rights (Rainbow,2002). As individuals women should be able to enjoy sexuality with the partner of their choice without fear of an unplanned pregnancy.
Not all within society agree with this perspective. For example the Catholic Church strongly disagrees with the practice of contraception. Others oppose contraceptive coverage on the grounds that should be an individual responsibility. They do not see this as a shared responsibility for society. Religious organizations were given an opt out clause by the HHS rule if contraception violated a tenet of faith.
On balance it is in society's interest to share the burden of contraception with women. This is based on the ethical principle of nonmaleficence embedded within the ethical theory of utilitarianism. Society directly benefits from contraceptive coverage. Each dollar spent on pregnancy prevention saves $3.74 of Medicaid costs. Contraception also reduces social welfare spending for women, infants and children (WIC) nutrition programs and other income support programs. Contraception directly reduces the adverse effects of poverty on women and children. Each of these indirect measures represents improved health for both women and children (IOM, 2011).
Pres. Obama has a unique opportunity to shape the future of America's families and children. PPACA is unique tool in the war on poverty. Through an Executive Order he has the option of overturning the organizational conscience clause and co-pays for non-generic contraceptive methods. He should take the steps regardless of the political fallout as he would improve the health of women, children and families. Politics trumped women’s health with the recent Plan B accessibility reversal.
Tonight a 17 year-old young woman on a date may have consensual sex with her boyfriend. She has a condom failure. How will she be able to prevent an unplanned pregnancy? A 15 year old girl will be sexually assaulted walking home from school. She is both embarrassed and terrified. How will she prevent pregnancy? Each of these cases are possible real world events. People who fully able to make responsible choices for their own health and wellbeing. Equity is another word for justice. Unfortunately, the administration was afraid of the politics associated with the prolife movement and did not act to protect the autonomy of young women. Contraceptive equity should include free OTC access to Plan B for women regardless of age. As citizens we should put the heat on the administration to stand up for young women and their right to prevent unwanted pregnancy.
Culwell, K., & Feinglass him, J. (2007). The association of health insurance with use of prescription contraceptives. Perspectives On Sexual & Reproductive Health, 39(4), 226-230.
Davidoff, F. and Trussel,J, Plan B and the politics of doubt. JAMA. 2006;296(14):1775-1778. doi: 10.1001/jama.296.14.1775 http://jama.ama-assn.org.ezproxy.undmedlibrary.org/...
Edney A. and Armstrong D. (2011). Morning after pill limit is first time ever us overrules fda. Bloomberg Businessweek. http://www.businessweek.com/...
Hayden, G. (2005). Contraceptive coverage grows, but significant challenges remain. Managed Care Interface, 1813-19.
Health & Human Services includes coverage for contraception - What is the next step?. (2011). Contraceptive Technology Update, 32(9), 97.
Health care reform: what does it mean for family planning providers?. (2010). Contraceptive Technology Update, 31(6), 61-64.
Insurance coverage for contraceptives. (2009). Nursing for Women's Health, 13(6), 524-525. doi:10.1111/j.1552-6909.2009.01079.x
Insurance coverage for contraceptives... 'position statement'. (2009). JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 38(6), 743-744. doi:10.1111/j.1552-6909.2009.01079.x
Is contraception part of preventive health?. (2010). Contraceptive Technology Update, 31(9), 103-104.
Kavanaugh, M. L., Jones, R. K., & Finer, L. B. (2011). Perceived and Insurance-Related Barriers to the Provision of Contraceptive Services in U.S. Abortion Care Settings. Women's Health Issues, 21(3), S26-31. doi:10.1016/j.whi.2011.01.009
Korman, E.R.. 2009 Kumino vs Torti http://www.nyed.uscourts.gov/...
Krishnamurti, T., Eggers, S., & Fischhoff, B. (2008). The impact of over-the-counter availability of "Plan B" on teens' contraceptive decision making. Social Science & Medicine, 67(4), 618-627.
Kuehn, B. (2011). US requires coverage for contraceptives, other women's preventive health services. JAMA: Journal Of The American Medical
Sonfield, A., Gold, R., Frost, J., & Darroch, J. (2004). U.S. insurance coverage of contraceptives and the impact of contraceptive coverage mandates, 2002. Perspectives On Sexual & Reproductive Health, 36(2), 72-79.
Rainbow, C. (2002). Descriptions of ethical theories and principles. Retrieved from http://www.bio.davidson.edu/...
Temkin, E. (2007). Contraceptive equity: the Birth Control Center of the International Workers Order. American Journal Of Public Health, 97(10), 1737-1745.