Will Free Birth Control Disappear Under President Trump?

How Contraceptive Coverage Could Change Under the New Administration

Various Birth Control Methods
How could insurance coverage for contraception change under the Trump Administration?. BSIP/UIG / Getty Images

Now that President Trump is in the Oval Office, woman are wondering whether insurance coverage for contraceptives is going to disappear, and whether they should get an IUD in the near future, in case they revert to costing several hundred dollars under his administration.

So let's take a look at the ACA's contraceptive mandate, the impact it's had, and what we can reasonably expect going forward.

Contraceptives Under the ACA

One of the more controversial provisions of the Affordable Care Act (Obamacare) is contraceptive coverage.

Under the ACA, all non-grandfathered health plans must cover—with no cost-sharingat least one version of each of the 18 different types of FDA-approved female contraceptives.

Although many of the ACA's provisions didn't take effect until 2014, the requirement that plans cover contraceptives has been in place since August 2012, for all new and renewing plans. For non-grandfathered plans that renewed after that point, contraceptive coverage was added at the first renewal. So by August 2013, all non-grandfathered plans included contraceptive coverage.

2015 Health Affairs study found that the ACA's contraceptive mandate was saving the average oral contraceptive user $255 per year, and the average IUD user $248 per year (without the ACA's contraceptive mandate, IUDs typically cost $500 to $1,000. Pre-ACA, this had to be paid up-front, but the savings are calculated on an annual basis, spread out over the years the woman has the device).

Under the ACA, insured women with non-grandfathered coverage don't have to pay anything at the time they get their birth control, assuming they opt for the contraceptives that their health insurers cover in full (the ACA requires health plans to cover at least one of each type; it does not require them to cover all versions of each type).

Although this is often referred to as "free" birth control, critics note that nothing is free. In reality, the cost of contraception is wrapped into the premiums that women and their employers pay for coverage. So for the sake of clarity, the discussion around free birth control in this article is referring to birth control that's provided with no cost-sharing at the time it's obtained.

Expanded Access to Contraception Reduces Abortions & Teen Birthrate

In November 2016, the CDC published data showing that by 2013, abortion rates were at an all-time low in the U.S.

Abortion opponents note that this could also be due to the plethora of laws that have been passed in various states to limit access to abortions in recent years. But evidence from Colorado—which is not among the states that have passed laws restricting access to abortions—indicates that access to contraceptives is indeed playing a key role: The Colorado Family Planning initiative began providing long-acting reversible contraceptives (IUDs and implants) to teens and low-income women in 2009, prior to the ACA's enactment.

By 2014, the teen birth and abortion rates had dropped by 48 percent.

IUDs and Implants Gain Popularity Under ACA Rules

The CDC also reports that highly effective long-acting reversible contraceptive (LARC) use is at an all-time high among American women. This is likely due to a combination of better education about LARC and the fact that the ACA took away the affordability barrier that sometimes prevented women from obtaining LARC prior the implementation of the ACA's requirements.

Will Trump and a GOP Congress Eliminate Fully-Covered Birth Control?

We don't yet know the full extent of what President Trump and the Republican-controlled Congress will do in terms of healthcare reform. But GOP lawmakers have put forth numerous proposals over the last several years, and Trump outlined his basic plan for reform during his campaign; it aligns closely with the overall strategy that Republicans favor. And the health care reform bills that have been introduced early in the 2017 legislative session have generally followed the same principles. So we have a basic idea of how health care reform is likely to proceed under a Trump Administration.

And in a move that may prove to be pivotal for contraceptive coverage, Rep. Tom Price (R, Georgia) was confirmed by Senate in February 2017 to be Secretary of Health and Human Services. In a 2012 interview with ThinkProgress, Rep. Price said that there is "not one" woman in the U.S. who couldn't afford contraception, in response to a question about what would happen—particularly for low-income women—if the ACA's contraceptive mandate was repealed.

Rep. Price went on to say that the ACA's contraceptive mandate was "trampling on religious freedom and religious liberty in this country."

So it's reasonable to assume that eliminating the ACA's contraceptive mandate might be one of Price's goals. He could do that by changing the regulations that define preventive care, since those guidelines were created by HHS, rather than defined in the ACA itself. Under the current regulations, which were developed in 2011, preventive care for women includes the full range of FDA-approved contraceptives. But those regulations might be subject to change under a Trump Administration HHS led by Tom Price.

Of course, congressional action could also come into play. If Congress introduces a replacement bill that calls for full repeal of the ACA (such as the Empowering Patients First Act that Price most recently introduced in 2015), the replacement portion of the legislation would be starting from scratch. But such a bill would be almost impossible to pass unless the replacement included a much more bipartisan solution than any of the reform proposals Republicans have put forth thus far, since a full repeal/replace bill would need at least 60 votes to overcome a Democratic filibuster in the Senate.

What Happens If the Contraceptive Mandate Is Repealed?

If lawmakers and/or HHS eliminate the ACA's contraceptive mandate, we would essentially return to the way contraceptive coverage worked prior to 2012. Birth control would still be available, but not required to be fully funded by private health insurance or Medicaid.

Some women would still have access to very robust health insurance with solid coverage of a wide range of contraceptives, but other women would have skimpier coverage. We would be back to a patchwork system of varying contraceptive coverage depending on where a woman lives and what type of health plan she has.

And although Rep. Price claimed in 2012 that "not one" woman was unable to afford contraceptives prior to the ACA's mandate, a 2010 survey conducted by Planned Parenthood found that 34 percent of women had "struggled with the cost of prescription birth control at some point in their lives."

In 2012, Georgetown University law student, Sandra Fluke, testified before a congressional panel regarding contraceptive coverage under the ACA. She testified that 40 percent of female Georgetown University law students reported that the university health plan's lack of coverage for contraceptives had caused them to struggle financially.

A return to cost sharing for contraceptives might not present much of a problem for women with incomes that put them in at least the middle class. But it could present a significant problem for lower-income women. And access to highly effective IUDs and implants could be dramatically impacted if their significant up-front costs cease to be fully covered by health insurance.

Sources:

Center for Disease Control and Prevention, Abortion Surveillance—United States, 2013. November 25, 2016.

Center for Disease Control and Prevention, National Center for Health Statistics. Trends in Long-acting Reversible Contraception Use Among U.S. Women Aged 15–44. February 2015.

Colorado Department of Public Health & Environment, Colorado's Teen Birth Rate Continues to Plummet. October 21, 2016.

Department of Health and Human Services, Health Resources and Services Administration, Updating the Women's Preventive Services' Guidelines, 2011.

HealthAffairs. Women Saw Large Decrease in Out-of-Pocket Spending for Contraceptives After ACA Mandate Removed Cost Sharing. Vol 34, No 7, July 2015.

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