Contraceptive coverage is growing, data show 

By Cynthia Dailard
Senior Public Policy Associate
The Alan Guttmacher Institute
Washington, DC

Since a decade ago, when the Alan Guttmacher Institute (AGI) first documented that private health insurance plans routinely excluded coverage of contraceptives from their prescription drug benefits,¹ family planning advocates have worked tirelessly to improve contraceptive coverage. These efforts have targeted Congress, state legislatures, courtrooms, and collective bargaining agreements between labor unions and employers. New research from AGI shows that this 10-year effort has yielded handsome dividends.²

According to AGI's study, contraceptive coverage improved dramatically between 1993 and 2002 among health plans purchased by employers for their employees.In 2001 and 2002, AGI researchers surveyed insurance companies across the nation, asking whether prescription contraceptives and other comparable drugs, devices, and services were covered in the "typical" managed care plans they wrote for their employers. The study did not look at the coverage provided by employers who self-insure, and as a result, covers about half of the private-sector employer-sponsored health insurance market in the United States.

In the new research, findings show that the proportion of typical plans covering the full range of reversible contraceptive methods tripled from 28% to 86%, and the proportion covering no method at all plummeted from 28% to 2%.

As a result of this enormous shift, several major coverage disparities that had been so glaring in 1993 have all but disappeared for this segment of the marketplace. For example:

• In 1993, coverage was much higher for abortion and sterilization than for reversible contraception (reflecting the industrywide bias toward surgical care and against preventive care). In 2002, this disparity had been eliminated.
• In 1993, different types of health plans enjoyed different levels of coverage, with coverage highest among health maintenance organizations (HMOs) and lowest among fee-for-service plans and preferred provider organizations (PPOs). In 2002, these variations were largely negligible.
• In 1993, there was considerable variation in coverage for different contraceptive methods. Most of these gaps had closed by 2002, and even newer contraceptive methods enjoyed high levels of coverage, including Lunelle (Pfizer, New York City, no longer marketed in the United States) and emergency contraception. (The study did not ask about coverage of the contraceptive patch or vaginal ring, both of which came on the market while AGI was fielding its survey.)

This improved overall coverage, and the improved coverage across contraceptive methods in particular, means that privately insured women are now better poised to select the contraceptive method that best meets their individual needs, lifestyle, and health situation, and thus the method that they can use correctly and consistently over time. This ability to exercise a true choice of contraceptive methods, unencumbered by price, is crucial to efforts to reduce rates of unintended pregnancy and abortion.

Mandates drive increase

Additionally, AGI’s study shows that the 20 state laws now requiring health plans to cover contraceptives on par with other prescription drugs have had a dramatic impact. (Fifteen states had laws in place at the time of AGI's study.) Plans in states with such contraceptive coverage mandates had better coverage overall and were more likely to cover individual methods than plans designed for states without mandates.

The impact of these laws extended far beyond their home-state borders. This is because plans designed at the national level by insurance companies operating in states both within and without mandates provide coverage everywhere in accordance with the state mandates. When those national plans are removed from the equation, plans designed specifically for states without mandates had far less extensive coverage. For example, fewer than half of the PPOs designed specifically in states without mandates covered all of the leading contraceptive methods; more than one in 10 such PPOs had no contraceptive coverage at all. In other words, significant gaps in coverage still remain.

Although the trends in contraceptive coverage are heartening, it is clear that family planning advocates have much to do before coverage is universal. More than half of all women of reproductive age live in the 30 states without a contraceptive coverage law. (To check your state’s law, visit the AGI website, www.guttmacher.org; click on "State Policies in Brief," then under "Prevention and Contraception, click on "Insurance Coverage of Contraceptives,"to see a list of state information.) AGI's research shows that coverage is still sorely lacking in these states, which highlights the need for more state laws. Similarly, about half of all Americans with employer-based insurance coverage obtain that coverage from employers who self-insure. These plans are beyond the reach of state mandates, and little is known about their level of coverage. Passage of federal legislation pending before Congress, known as the Equity in Prescription Insurance and Contraceptive Coverage Act is necessary to guarantee coverage for women in states without mandates and for individuals in self-insured plans.

Similarly, enhanced enforcement of gender discrimination laws, coupled with other efforts to persuade employers to provide coverage, also will play vital roles. In short, a multipronged strategy to improve contraceptive coverage still is needed to ensure that women have the contraceptive coverage they need to avoid unintended pregnancy.

References

1. Alan Guttmacher Institute. Uneven & Unequal: Insurance Coverage and Reproductive Health Services. New York City: Alan Guttmacher Institute, 1994.

2. Sonfield A, Gold RB, Frost JJ, et al. U.S. insurance coverage of contraceptives and the impact of contraceptive coverage mandates, 2002. Perspect Sex Reprod Health 2004; 36:72- 79.