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When Margaret Sanger first began pushing for the birth control pill, people were getting around town in horse-drawn buggies. Sex for sex's sake was still a radical notion that had to be kept underground. Public support of contraception could land you in jail.
Fast-forward some 80 years and women are still facing down the forces that brought us illegal abortions and contraband diaphragms covered in plain, brown wrappers. Eighty-five percent of sexually active women now take the pill at some point in their lives. Yet despite the huge market or perhaps because of it the vast majority of insurers refuse to pay for oral contraceptives.
Most health insurance does cover prescription drugs in general, mind you. But more than 60 percent of managed-care companies wiggle out of paying for the pill or other contraceptives, according to the most recent study, done in 1995. And traditional insurers are even worse, with a mere 15 percent of them paying for all five of the most used contraceptives. Outpatient medical visits must also be paid for by the patient if they involve birth control. Even women who take the pill for medical reasons, such as management of ovarian cysts, often end up paying roughly $30 a month for it.
Finally, after years of placidly forking out for the pill and other contraceptives, women are making noise about inequity in contraceptive coverage. Over the past year, seven states have passed "pill bills" that would require insurers to cover the five most frequently used types of birth control (the pill, Depo Provera, the IUD, Norplant, and the diaphragm). Connecticut's passed just weeks ago.
But, as always, progress on the contraceptive front is excruciatingly slow. Senator Olympia Snowe's bill, which calls for birth control coverage nationwide, is now more than two years old. This week, Snowe, a Republican from Maine, is expected to reintroduce the legislation yet again but experts say it is unlikely to become law any time soon. Even as those seven state-level pill bills passed, another eight were being shot down. And five of the laws that did pass contained "conscience clauses," which allow companies, those bastions of moral thinking, to opt out of complying with the law if they feel uneasy covering contraception.
Meanwhile, more than a dozen other state proposals are stuck in legislative limbo. In New York, that includes a stand-alone pill bill sponsored by upstate assembly member Susan John as well a proposal introduced by Manhattan assembly member Deborah Glick that would mandate coverage for various medical tests as well as birth control. Both are expected to be gathering dust in the state senate when the legislature breaks for summer.
While the legislature stalls, women will continue paying almost 70 percent more out of their own pockets than men for their health care. Most probably won't think anything of it, since the exclusion of birth control has come to feel like just another unfair fact of life. In fact, while HMOs and other types of "prevention-oriented" companies have spotty coverage for birth control, most are still doing better than previous insurers. And the further back you go, the worse the coverage was. As recently as the late '70s, when the Pregnancy Discrimination Act was passed after a long fight, prenatal care and childbirth were also often excluded by insurance.
It was only when other, less troublesome health problems started getting coverage that the double standard around birth control became glaring. The infertile have struggled long and hard to get insurance to cover their bills. And perhaps their relative success getting coverage for high-tech treatments, many of which were developed well after the pill, should have been expected; they were trying to have babies, while women using birth control were trying not to.
And then came the final straw: men started pleading for and getting coverage for the famed Viagra. It turns out that men's desire to have sex often counts as medical necessity, which often must be claimed to get Viagra covered. But, for the pill, just wanting to have sex is not enough. For women, insurance will usually only come through if they are combating disease.
"You never even read about the issue of whether contraceptives were covered before Viagra," says Elizabeth Siegel Watkins, author of On the Pill. Watkins, a historian, is puzzled by the fact that so popular a drug has been blacklisted by insurance companies. "Everybody loved the pill. It's one of the few points of consensus between the prolife and prochoice movements."
Indeed, it's hard to object to the basic idea behind the new pill bills. Forbiding insurers to exclude birth control coverage would inevitably push down the abortion rate, a goal everyone agrees on. And, according to a recent study, savings on the costs of prenatal care and childbirth would more than pay for the estimated $21.40 contraceptive coverage would add on average to yearly insurance costs ($17.12 of which would be paid by employers).
All of which may explain why, in New York, the Conservative Party poses its objections to Glick's Women's Health and Wellness Act as business concerns. They complain that the bill would raise insurance costs. Most conservatives as well as, not surprisingly, insurance industry lobbyists are opposed to mandates in general, preferring to leave such matters to the free market. Insurers also like to point out that birth control coverage is often determined by employers, who don't buy the optional riders that would cover it because they cost extra.