Study Finds Lower Out-of-Pocket Costs and Expanded Access to LARCs
By Emily A. Eckert
Long acting reversible contraceptives (LARCs)—which include intrauterine devices (IUDs) and implants—are commonly considered the most effective form of birth control. Fewer than 1% of women who use IUDs will become pregnant within a year, in contrast to 18% who use only condoms to prevent pregnancy, and 9% who use the pill. Traditionally cost-prohibitive for many women, IUDs and other LARCs are becoming increasingly more available as the Affordable Care Act (ACA) brings down out-of-pocket costs for consumers.
Rules for the contraceptive mandate were proposed by the U.S. Department of Health and Human Services (HHS) in August 2011. Under the Affordable Care Act, the proposed regulations require that all health plans sold on insurance exchanges cover various methods of birth control with no cost-sharing or out-of-pocket costs, and that all employers offer health plans that include free contraceptive services. After HHS issued the proposed rules, it didn’t take long for religiously affiliated nonprofits and for-profit businesses to get up-in-arms about the mandate.
Numerous nonprofits including hospitals, charities and universities, as well as huge for-profit establishments like Hobby Lobby took a stand against the contraceptive mandate, arguing that it was a direct violation of their First Amendment right to religious liberty. They argued that it was against their faith to include contraceptive products and services to their employees as part of a group health plan. This opposition made it all the way to the U.S. Supreme Court, and on June 30, 2014, a ruling was released that closely-held, for-profit organizations could “opt out” of providing contraception to their female workers. The Court ruled that the “HHS regulations substantially burden the exercise of religion,” and that “enforcement of the HHS contraceptive mandate against the objecting parties (i.e. Hobby Lobby) in these cases is unlawful.”
Nevertheless, the ACA requires that privately insured women be able to obtain contraceptive services and supplies without cost-sharing. So for the employees of closely-held, for-profit organizations with religious exemptions to birth control, contraceptives are still accessible (thanks to HHS’ July 2015 final regulations on the mandate), just with a few more hoops to jump through.
The expanded availability of contraceptives, particularly LARCs, will have a tremendous impact on women and families. A new study by researchers at the Guttmacher Institute suggests that the IUD may become a more prominent contraceptive method for women of childbearing age, as the ACA eliminates the high upfront costs these women would normally have to pay.
Analyzing administrative data for 417,221 women, the researchers examined records of insurance inquiries made by providers of patients interested in getting an IUD. The study found that, post-ACA, fewer women would face out-of-pocket costs for an IUD. Specifically, in January of 2012, 58% of women would have incurred costs for an IUD, compared to only 13% in March of 2014. The report proves that “financial barriers to one of the most effective methods of contraception fell substantially following the ACA.”
The Guttmacher study is further evidence that the ACA’s contraceptive mandate works for women. Considering that the typical woman spends “less than three years pregnant or trying to become pregnant, and more than 30 years trying to prevent pregnancy,” contraceptives are an essential part of women’s lives. That said, it is ludicrous that some women remain unable to access this critical health care without facing miles of red tape to avoid a conflict with their boss.
And what about women enrolled in public health benefit programs, like Medicaid? Medicaid is traditionally thought of as insurance for the poor or extremely low income. Many health care providers and speciality-service providers do not accept Medicaid patients due to stigma, capacity, and low reimbusement rates, among other reasons. So how do women with Medicaid access LARCs, and how has this coverage changed since the passage of the ACA?
Besides the fact that IUDs and other LARCs are traditionally expensive, most insurers have not yet figured out how to properly incentives providers to adminster LARCs. Take, for example, the practice of inserting IUDs immediately after childbirth. Hospitals traditionally bundle delivery-related care into one, average payment. Since all of the services (epideral, delivery, breastfeeding support, etc.) are lumped together, there is no incentive for a physician to recommend an IUD to a woman who has just given birth (keep in mind, LARCs are expensive for hospitals, too). If they aren’t receiving a reimbursement, they aren’t in favor of giving them out (especially to low-income Medicaid patients). Alternatively, if a LARC is inserted in the outpatient setting, perhaps at a six week postpartum visit, insurers are able to provide a separate payment for the visit, the device, and the insertion. It all comes down to nickles and dimes, but just as the ACA has made IUDs more available for insured women, so too have some state Medicaid programs.
In a recent study published in Contraception, researchers found a rapidly increasing number of Medicaid agencies “providing enhanced reimbursement specifically for LARC inserted right after birth.” Since 2012, 18 state Medicaid agencies (and the Disctrict of Columbia) have begun to pay specifically for immediate postpartum LARC (IPLARC). These agencies and state policymakers have recognized the health and financial benefits of inserting LARCs after birth. Researchers predict a significant impact in the number of low-income women receiving the service. IPLARCs are an ideal scenario for these women, who often do not have access to transportation or childcare to make it to their six week postpartum appointment.
Study predictions indicate that LARCS, the most effective yet most costly form of birth control, will now become more popular among reproductive-age women thanks to the ACA. Prior to implemenation of the contraceptive mandate, the upfront, out-of-pocket cost for an IUD could go as high as $1,000, not including insertion or removal fees or the cost of the doctors visit. If use among reproductive-age women does increase as a result of this legislation, unintended pregnancy rates could plumate, as could the number of abortions in this country.
Whether you have Medicaid or private insurance through an employer, your parents’ plan, or the ACA, the bottom line is, you are entitled to preventive services without cost-sharing, including all FDA-approved contraceptive methods.
If you or someone you know is wrongfully paying out-of-pocket costs for your birth control prescription, visit coverher.org.
Emily A. Eckert is a Health Reform Program Associate at the Association of Maternal & Child Health Programs in Washington, DC. The views expressed in this blog are her own.