Why Birth Control Should Be Free

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Photo: BSIP/UIG/Getty Images

Many of President-elect Donald Trump’s plans for our country are still a mystery, but one thing is clear: He’s not a fan of the Affordable Care Act, also known as Obamacare, and that means free birth control might soon be a thing of the past.

During the campaign, Trump vowed to repeal the ACA entirely, though he recently said he’s open to keeping certain parts of the law, like the fact that people can’t be denied coverage because of preexisting conditions. House Speaker Paul Ryan was on CNN on Sunday to talk about the ACA, and he did not reassure us. When CNN’s Jake Tapper asked about the birth-control provision, Ryan said he wasn’t going to “get into all the nitty-gritty details of these things.” But birth control is far from a nitty-gritty detail: It’s important preventive health care, a fact the federal government has acknowledged since August 2011. And it should be free.

One of the tenets of the ACA is that if there’s strong scientific evidence that a preventive service has health benefits, then people shouldn’t have to pay for it. After the ACA became law, the Department of Health and Human Services commissioned an independent body, the Institute of Medicine (IOM), to review which preventive services are necessary for women’s health, and the group said insurers needed to cover eight more things. These included annual well-woman visits, screening for cervical cancer and HIV, screening for domestic violence, breastfeeding supplies and counseling, and, should a woman not want to get pregnant, access to every FDA-approved method of birth control that can be prescribed by a health-care provider, including emergency contraception and sterilization. (Plans aren’t required to cover abortion drugs and male sterilization, a.k.a. vasectomies, and certain religious employers are exempt from birth-control coverage.)

Contraception has health benefits, as the HHS points out, because it can reduce women’s cancer risk — combined birth-control pills can lower your risk for ovarian and endometrial cancers, anyway. Plus, certain types of birth control can treat conditions like endometriosis, polycystic ovary syndrome (PCOS), uterine fibroids, and heavy menstrual bleeding.

But let’s set that aside for a moment, because preventing unintended pregnancies on its own is beneficial for women’s and children’s health. Full stop. When the IOM finished its scientific report, the group noted this fact in a release:

Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy. Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which raise their chances of health and developmental problems.

Unintended pregnancies are still too common, and they disproportionately affect lower-income women and women of color. In 2011, 45 percent of the 6.1 million pregnancies in the United States were unintended. After excluding miscarriages, 42 percent of unintended pregnancies ended in abortion and 58 percent ended in birth. Poor and low-income women were less likely to have an abortion and as a result had a higher unintended birthrate than higher-income women. The sheer number of unintended pregnancies is why the IOM urged the federal government to cover all forms of birth control, including long-acting methods like IUDs and implants, which are more than 99 percent effective at preventing pregnancy.

But since Trump was elected, some people (women included) have been vocal about the fact that they don’t want to pay for others’ birth control. They argue that Obamacare is too expensive and they’re struggling to pay for it already, or that it’s unfair for contraceptives to be free when other people can barely afford drugs for heart conditions or diabetes. And, of course, some revert to the familiar anti-sex argument: “Why can’t women just keep their legs closed?”

These arguments not only overlook some basic facts — many women use birth control for health reasons, people can and do have non-procreative sex — but they also ignore the economics of health insurance: People who don’t need to see the doctor very often are the cheapest to cover. Ergo, a nonpregnant woman costs an insurer less than a pregnant woman.

The costs of unintended pregnancy are staggering. In 2010, 51 percent of the nearly 4 million births in the United States were paid for by government health insurance like Medicaid and the Children’s Health Insurance Program. Public insurance covered 68 percent of the 1.5 million births that were unplanned, versus the 38 percent that were planned. Overall, the government spent $21 billion on unintended pregnancies that year, or about $336 for every woman between the ages of 15 and 44.

Some like to suggest that people buy condoms if they don’t want to get pregnant, but condoms are only 82 percent effective with typical use. (Plus, there are women in abusive relationships whose partners refuse to use contraception or sabotage their birth control.) When you move into the realm of prescription methods (pills, patches, rings, shots, implants, and IUDs), the effectiveness jumps up to between 91 and 99 percent. That’s why it’s so important to give women access to the most effective method that works for them and, increasingly, that’s an IUD or implant. These devices have relatively high upfront costs — up to $1,000, though the Liletta IUD was designed for family-planning clinics and costs providers $50 — but they last between three and ten years.

No matter the type, birth control is preventive care, and completely unlike drugs for diabetes, heart disease, or depression, which treat existing conditions. It has the power to prevent health problems and save vast sums of money — in this way it functions more like a vaccine than a medication. And this is to say nothing of the power it gives women to control their educations, their earning potential, and the shape of their lives.

The Best Way to End Poverty Is to Start With Birth Control