Access to Birth Control, Sex Ed, and Women’s Health Services Is at Risk: The Politics of Contraception in Modern America

July 25, 2018

Political protesters may shout and hold signs telling the U.S. government to “get your laws off my body,” but the current presidential administration is trying to do just the opposite.

While women’s contraception has until recently been readily accessible and free of cost under most healthcare plans through the Affordable Care Act, implemented when Democrat Barack Obama was president, politics can play a significant role in how that can change. Under Republican President Donald Trump, birth control accessibility and affordability has been threatened.

Related: Birth Control in America: A Brief History of Contraception 

“The Trump administration takes a very different approach than the Obama administration did,” said Adam Block, PhD an assistant professor of public health at New York Medical College in Valhalla, New York. The Obama administration wanted to make birth control available more broadly. The Trump administration is shifting the decision about [birth control access] back into the hands of employers.”

Related: What Is Emergency Contraception?

As a result, how people obtain and what they pay for birth control depends on their insurance coverage (or lack thereof), their finances, and what they learn about their options either from a healthcare provider or another source.

How the Affordable Care Act Works for Contraception

While Obama was president, the Affordable Care Act (ACA) became law in 2010 (1). It provided comprehensive health coverage for everyone in the United States to pay for and get health insurance. The ACA allowed for women to pay nothing for their contraception (2), including birth control pills, IUDs, sterilization, and emergency contraception, among other choices.

When the ACA initially passed, there were exemptions for religious organizations such as a Catholic Church employing primarily priests and nuns; Catholic hospitals employing thousands of nonreligiously affiliated people were not allowed the exemption. But in 2012, the private arts and crafts retailer Hobby Lobby brought suit against the Obama administration and asked for the same religious exemption. In 2014, the U.S. Supreme Court ruled (3) in Hobby Lobby’s favor.

In October 2017, after Trump became President earlier in the year, he and his administration allowed any employer to apply for a moral or religious exemption if the business wanted to deny contraception coverage through the employer’s health insurance plan based on sincerely held religious beliefs opposed to such coverage.(4)

The issue has been challenged by several states and is now being debated in the courts, said Block.

Related: Shop Now for Affordable Birth Control in Case of a Coverage Change

New Question at Stake: Who Pays for Birth Control?

As the policy works its way through the court system, the question of who pays for birth control is at stake.

As with abortion, birth control availability may differ depending on how conservative a state is, should the policy on contraception and religious/moral exemptions move forward, said Block.

Contraception Options Vary by Cost and Insurance Coverage

Block said that some ACA-based insurance plans, typically the most basic ones, might offer only state minimum requirements— so perhaps just birth control pills and hormone injections but not costlier methods like IUDs. In these cases, Block says people can always buy more coverage to make more options available.

“People know their earnings,” he said. “They should budget to be able to purchase birth control, shop around, and see if there are generic versions available or nonhormonal contraceptives” to see how to lower costs.

Paying Out of Pocket for Birth Control Can Be Prohibitively Expensive

But for lower-income women, such policies have a different impact, said Erica Sackin, the director of political communications for Planned Parenthood Federation of America and Planned Parenthood Action Fund, both based in Washington, DC. “For a number of women, even when they have to pay an insurance copay, let alone out of pocket, contraception can be too expensive. If you have to pay out of pocket, birth control pills can cost up to $600 a year, for example. If you are young, a student, etc., it can be completely unattainable.”

What Could Happen if Contraception Laws Change

If contraception is no longer covered by U.S. health insurance plans, the number of teen pregnancies and unintended pregnancies is sure to rise, Sackin said. Under the ACA, the birth control benefit meant that 62.4 million women had access to no-copay birth control. As a result, teen pregnancy is now at an all-time low and the rate of unintended pregnancy is at a 30-year low, said Sackin. With the current political climate, “the Trump administration is completely walking this back,” she said. As of 2017, the Trump administration made changes that mean birth control is no longer guaranteed, said Sackin.

Limiting Access to Birth Control Education, Options

Another issue tied up in the courts that directly affects women and their contraceptive options is Title X (5), the nation’s grant program for affordable birth control. It ensures that every person has access to preventative care, birth control, and STD treatment and serves 4 million people a year, said Sackin.

What to Know About Possible Changes Such as Defunding Groups Like Planned Parenthood

In February 2018, the Trump administration made a Funding Opportunity Announcement (FOA), (6) saying it was changing the priorities of the Title X program, said Sackin. The FOA stipulates that all future Title X grants will be prioritized for organizations or providers that counsel patients only about fertility awareness, abstinence, and/or marriage counseling, rather than organizations that specialize in the full range of birth control and other options in reproductive healthcare. (Any other organizations currently receiving funding through Title X will see it end this year, even if the grant was scheduled to last longer.) In the past, grants were distributed to those who were covering the greatest patient needs. Planned Parenthood and other organizations have gone to court with the Trump administration over this, and the case is ongoing, Sackin said.

Legal Changes May Penalize Groups That Deliver Reproductive Health Services

The FOA change effectively penalizes organizations that provide reproductive health services along with basic healthcare, as Planned Parenthood does, and prevents them from getting such funding.

Title X: What Is the Gag Rule?

The Trump administration also introduced the gag rule (7) as part of Title X. While it is currently in a 60-day period seeking comments from the public, the gag rule would make it illegal for any healthcare worker at an organization or clinic funded by Title X to be able to tell patients how they can legally and safely access abortion. It would also remove the guarantee that providers aren’t withholding information about pregnancy options, and it would open the door to having more pregnancy crisis centers, which are antiabortion advocate organizations that don’t normally provide healthcare, said Sackin. “If you go to one of those, if you were recently diagnosed with cancer, your doctor could refuse to tell you that an abortion could save your life,” she said. The gag rule also imposes restrictions on the ability of organizations like Planned Parenthood to participate in the Title X program.

Who Opposes Changes to Title X?

As a result of the gag rule, many medical groups (8) also oppose the proposed changes to Title X, including the American Academy of Pediatrics, American College of Obstetricians and Gynecologists (ACOG), and Power to Decide, the campaign to prevent unplanned pregnancy. They say that the changes violate the oath healthcare providers take when they become providers: to do no harm and tell patients about all the healthcare options available to them. “[These changes] eliminate the guarantee that a doctor will give you all the healthcare information that is available,” said Sackin.

The Potential Impact of Funding Changes for Women

The FOA fight is an attempt to push women to either not use any form of birth control except abstinence or the rhythm fertility method, and it is dangerous,” said Sackin. “The rhythm method is often less effective than other forms of birth control. If you have an abusive relationship or have less control over the details of your life, this is not a method that will work for you. When we have seen states try to do similar policies that remove women’s access to healthcare, women’s health suffers. The rates of unintended pregnancies go up.”

While the fight surrounding Title X continues, particularly over the gag rule, it isn’t safe to think that it will be overturned by the courts. Historically, the Reagan administration tried to do something similar (9) about 30 years ago. It was challenged in the courts, but it was ruled to be constitutional in 1991. (The Clinton administration rescinded the policy shortly after coming into office.) But the fact that it was deemed constitutional means that the current battle over changes to Title X could ultimately become law.

Healthcare Debates about Women’s Health, Reproductive Rights Spur Political Change

In response to the sweeping changes that the Trump administration has already put into law as well as the pending legislation that may become law, more women have chosen to run for office at the local, state, and national levels to try to promote issues, such as reproductive health, women’s health, and other topics.

“Because there are so many people making consequential decisions about healthcare and so many policies are slipping under the radar, it really threads the needle about what is in place and how it affects your healthcare,” said Sackin. Consequently, “it’s not a coincidence that we are also seeing historic numbers of women (10) fighting for change and, both marching in the street and running for office. One in five people in this country have taken such action since Trump came into office and the top reason they list is for women’s rights,” she said.

Supreme Court Changes May Lead to Weaker Reproductive Rights 

In early July, Trump named Brett Kavanaugh, a judge on the U.S. Court of Appeals for the DC Circuit, as his nominee for an opening on the Supreme Court. (11,12) Democrats fear that Kavanaugh, a lifelong Catholic, may help to overturn the rulings on Roe vs. Wade that legalize abortion in the United States. At press time, the Planned Parenthood Action Fund was organizing around the nomination, hoping to convince some Republican senators as well as some Democratic senators who may be undecided to vote against Kavanaugh’s nomination to the nation’s highest court. Kavanaugh needs 50 votes to win; there are currently 49 Democratic senators and 51 Republican senators. (13)


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