HHS adds contraception coverage — What is the next step?

Guidelines call for preventive health services at no additional cost

How many times have you prescribed oral contraceptives (OCs) for a woman at one visit, only to find that she has discontinued the method by the next exam due to financial inability to cover her insurance copay on the pill pack? Get ready for that scenario to change. The federal government has adopted additional guidelines for women's preventive services that call for coverage without cost sharing in new health plans starting in August 2012.

In adopting recommendations from the Institute of Medicine (IOM), the Department of Health and Human Services (HHS) added the following preventive services without cost sharing:

  • well-woman visits, which include an annual well-woman preventive care visit for adult women to obtain the recommended preventive services and additional visits if women and their providers determine they are necessary;
  • screening for gestational diabetes for women 24-28 weeks pregnant, as well as to those at high risk of developing the condition;
  • access to human papillomavirus (HPV) testing for women 30 years and older every three years, regardless of Pap smear results;
  • sexually transmitted infection counseling;
  • HIV screening and counseling;
  • breastfeeding support, supplies, and counseling, giving pregnant and postpartum women access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment;
  • domestic violence screening and counseling;
  • contraception methods approved by the Food and Drug Administration (FDA) and contraceptive counseling.

"There is no doubt that birth control is basic health care for women," said Vanessa Cullins, MD, MPH, vice president for medical affairs at Planned Parenthood Federation of America in New York City in a statement following the HHS announcement. "Covering birth control without co-pays is one of the most important steps we can take to prevent unintended pregnancy and keep women and children healthy."

For nurse practitioners and other healthcare providers, full coverage of birth control means one thing above all else: the ability to provide better care and counseling to patients, says Susan Wysocki, WHNP-BC, FAANP, president and chief executive officer of the Washington, DC-based National Association of Nurse Practitioners in Women's Health.

In a survey of women ages 18-44, 31% of women using reversible birth control said they would like to switch from their current method to something else but couldn't do so due to costs.1 "Coverage of all FDA-approved prescription contraceptives means that healthcare providers can offer the broad range of available birth control options, even to patients of limited means," observes Wysocki. "The result should surely be contraceptive choices more closely aligned with each woman's needs, more consistent use, and, ultimately, fewer unintended pregnancies."

Choices now available

Long-acting reversible methods such as the intrauterine device and the contraceptive implant have high up-front costs. Adoption of the HHS guidance removes that barrier for insured women, notes Claire Brindis, DrPH, MPH, director of the Philip R. Lee Institute for Health Policy Studies and a codirector of the Bixby Center for Global Reproductive Health, both at the University of California in San Francisco.

"We know right now that about nine out of 10 health insurance plans do cover the visit and in part, the contraception, but the copay has often been a barrier, particularly around long-acting reversible contraception," says Brindis, who served as a member of the IOM committee which developed the current guidance.

Compared to many Northern European countries (with their attendant lower rates of unintended pregnancies and induced abortions), use of implantable and intrauterine contraception remains low in U.S. women, says Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine – Jacksonville.

One reason behind the low use of long-acting reversible contraception (LARC) is their high up-front costs, which often presents a barrier even for otherwise well-insured young women, says Kaunitz. "It is my hope that this HHS decision means our patients will have far greater access to LARC methods," he states.

Advocacy not over

An interim final rule was released alongside the women's prevention guidelines to give religious organizations the choice of buying or sponsoring group health insurance that does not cover contraception if it is inconsistent with their beliefs. This proposed exemption gives the Association of Reproductive Health Professionals (ARHP) and reproductive health advocates pause.

"ARHP encourages HHS to rethink this ideologically-based action by either reversing it or crafting a very narrow exemption policy," states a release issued by the Washington, DC, association.2

This exemption was not required by the healthcare reform law, notes Adam Sonfield, senior public policy associate in the Washington, DC, office of the Guttmacher Institute. Religious groups have challenged and lost in the courts when it comes to advocating for such exemptions. In 2006, the Court of Appeals for the State of New York upheld the state's Women's Health and Wellness Act against a challenge by Catholic Charities and other religious groups. The New York legislation requires insurance companies to cover women's preventative health care and includes a mandate that insurance plans that cover prescription drugs also must include contraceptive coverage. The New York court's action followed a similar decision in 2004 by the California Supreme Court, which rejected a challenge to a nearly identical state statute. In both cases, Catholic Charities was suing not to create a new religious exemption, but because the religious exemption included in the New York and California laws was not broad enough to include Catholic Charities, explains Sonfield.

The U.S. Supreme Court in 2007 turned down an appeal by Catholic Charities of the Diocese of Albany and eight other New York-based Catholic and Baptist organizations to review the New York state court decision.

Keep eye on changes

Keep in mind that not all insurance plans will be immediately affected by the preventive services requirement. Existing plans are "grandfathered" so long as no significant negative changes, such as cutting benefits or raising cost-sharing, are made to them, according to information released by HHS.3 Most plans will likely lose grandfathered status within a few years.

When the Affordable Care Act was enacted in 2010, it included preventive services recommended by the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices, and the Bright Futures Guidelines. No comments were raised by insurance companies at that time as to increasing costs for coverage, notes Brindis. However, with the addition of the eight preventive services for women, talk already is circulating regarding potential insurance cost hikes.

While there are relatively little data from the private sector, publicly funded contraceptive services and supplies have been shown to be cost-effective.4 For every $1 invested in public dollars for contraception, $3.74 in Medicaid expenditures are saved that otherwise would have been needed to provide pregnancy-related care, such as prenatal, labor, delivery, and postpartum care, for women's unintended births, as well as one year of medical care for their infants.4 A recent National Business Group on Health report concludes that even if contraception were exempted from cost-sharing, the savings from its coverage would exceed the costs.5

"Clearly, with the cost-effectiveness of family planning services shown over and over again, wouldn't the insurance companies rather pay for the contraceptive than pay for the pregnancy?" Brindis asks.

References

  1. Frost JJ, Darroch JE. Factors associated with contraceptive choice and inconsistent method use, United States, 2004. Perspect Sex Reprod Health 2008; 40:94-104.
  2. Association of Reproductive Health Professionals. ARHP Applauds New HHS Prevention Guidelines but Takes Exception to Religious Exemptions. Press release. Accessed at http://www.arhp.org/modules/press.
  3. Department of Health and Human Services. Fact Sheet: Keeping the Health Plan You Have: The Affordable Care Act and "Grandfathered" Health Plans. Accessed at http://www.healthreform.gov/newsroom.
  4. Sonfield A. Contraception: an integral component of preventive care for women. Guttmacher Policy Review 2010; 13(2):2-7.
  5. Sonfield A. The case for insurance coverage of contraceptive services and supplies without cost-sharing. Guttmacher Policy Review 2011; 14(1):7-15.