States address coverage for contraceptives
More than half of U.S. state legislatures have addressed insurance coverage for prescription contraceptives this year, but the jury is still out on which bills will be signed into legislation.
"Several of the bills are moving, and moving quickly, and seem to be doing well," observes Rachel Benson Gold, assistant director for policy analysis with the Washington, DC, office of the Alan Guttmacher Institute. "It was a major priority for the state legislatures this year."
The state of Georgia has joined Maryland as the second state with a comprehensive contraceptive coverage law. The Georgia law, which mandates that health policies covering prescriptions include prescription contraceptives as well, now has been signed into law.
The Washington office of the Alan Guttmacher Institute reports that 60 bills concerning contraceptive coverage had been introduced in 31 states as of Contraceptive Technology Update’s press time. That compares favorably with 1998, when 20 states introduced such bills.1 Bills in Calif ornia, Hawaii, Illinois, North Carolina, Vermont, Washington, and Nevada had passed at least one house and were still in play. Alaska, Conn ecticut, New Jersey, New York, and Oklahoma had bills passing at least one committee, as did Florida, with a bill requiring coverage of oral contraceptives only.
Bills on contraceptive coverage were defeated or died at the end of sessions in Idaho, Indiana, Nebraska, New Mexico, and Utah. Bills were introduced — but no action was taken — in Louisiana, Maine, Massachusetts, Missouri, Montana, New Hampshire, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, and West Virginia.
Some of the state bills are modeled after the federal Equity in Prescription Insurance and Contra cep tive Coverage Act, whereby if coverage is offered for prescription drugs, prescription contraception must be covered as well, says Marilyn Keefe, director of public policy for the National Family Planning and Reproductive Health Association in Washington, DC. Other bills appear to have less substance. The focus should remain on the fact that prescription contraceptives are the only class of drugs routinely excluded from health plan coverage, she says.
Offerings vs. mandates
Last year, Maryland became the only state to pass legislation requiring private insurers to provide comprehensive coverage for contraceptives if they covered the cost of prescription drugs. Virginia and Hawaii passed laws that require health insurers to offer employers the option of including coverage in the benefit plans for their employees, but the laws do not mandate coverage.
A mandate to offer, which is included in the Virginia and Hawaii law, says the insurer has to offer the coverage to the employer, Gold explains. It is then up to the employer to decide whether to include contraceptive coverage in the policy he or she purchases for employees.
An actual contraceptive coverage mandate requires the coverage to be included in the policy the employer buys. Mandates often are adopted at the state level, says Gold, who points to state insurance mandates for such health issues as mammograms and preventive health care for children.
The introduction of state contraceptive coverage legislation also has raised issues of conscience, as certain insurance providers, employ ers, and even pharmacists look to claim conscientious objections in providing certain or all contraceptive methods.
At CTU press time, an amendment had been added to the North Carolina Senate contraceptive equity bill that would allow employers to exclude coverage of emergency contraception and mife pristone. The Washington, DC-based Association of Reproductive Health Professionals has asked that the amendment be rejected and points to the important public health benefits of providing emergency contraception.2
New Jersey legislators are considering a proposed conscience clause by pro-life pharmacists who wish to claim conscientious objection to dispensing emergency contraception, which they claim is an abortifacient.3
"The contraceptive coverage issue highlights several fault lines at the intersection of religious beliefs and the provision of health care services," Gold writes in a special series of articles that examined key policy questions on the subject of contraceptive coverage.4 Individual providers, health care plans, and employers all may seek legislation to invoke conscientious objections.
Attention should focus on making sure women have access to services, Gold says. Many creative solutions have been devised to give those who desire an "arm’s length" to contraceptive coverage to opt out of contraceptive coverage plans, while making sure women have clear access to the full complement of approved contraceptive devices.
One example that respects beliefs but ensures access is the contraceptive coverage bill introduced in the state of Washington. The bill would allow an individual employed by a religious employer to bypass the employer and buy contraceptive coverage directly from the insurer at the same cost as could the employer. The employer could exercise his or her religious beliefs, but the employees who need coverage still would have access to it.
The contraceptive coverage bill for federal employees, which passed last year, included an exemption for religious health plans. Because employees in the federal system are allowed to choose plans, they simply could choose one that includes contraceptive coverage, Gold says.
"What is key to that situation is notification and information, because you can only make those informed choices if you have the information to make them," she observes. "I think that set us down the path of saying, We need to keep our eye on the issue of access on the other side.’"
1. Donovan P, Figdor E, Sonfield A. State legislatures in 1998: On 2 roads to goal of prevention.’ The Guttmacher Report on Public Policy — February 1999. New York; 1999.
2. Associ ation of Reproductive Health Professionals. ARHP urges N.C. state Senate to reconsider amendment to contraceptive equity bill. Press release. Washington, DC; April 5, 1999.
3. Henry J. Kaiser Family Foundation. Conscience clause: New Jersey pharmacy bill in the works. Kaiser Daily Repro duc tive Health Report. Menlo Park, CA; March 7, 1999.
4. Gold RB. Contraceptive coverage: Toward ensuring access while respecting conscience. The Guttmacher Report on Public Policy — December 1998. New York City; 1998.