Alibi V.20 No.32 • Aug 11-17, 2011 

Miss Diagnosis

Prevention Goes Girlie

Free birth control and other big bonuses

Back in the good ol’ days, Congress somehow managed to pass a little piece legislation called the Patient Protection and Affordable Care Act (nostalgic sigh). This health reform law says insurance companies must fully cover certain preventive health care services without charging their customers any out-of-pocket expenses, like co-pays, deductibles and co-insurance. The rationale behind this is simple: Prevention saves lives and dollars.

The health reform law doesn’t spell out the exact services to be covered. Today’s pap smear might be replaced by tomorrow’s cancer-blasting nanobots. So health reform uses the recommendations of national experts.

Then the Institute of Medicine advised in July that birth control be part of those preventive services. On Monday, Aug. 1, that suggestion was incorporated into the health reform law, which means birth control will be free for women who pick up new insurance policies beginning August 2012.

The institute’s guidance attracted plenty of fans. Yet the suggestion that women ought to have access to free birth control predictably outraged people who confuse contraception with abortion. The recommendations do not include methods that cause abortion. There aren’t any contraceptive methods (including the morning-after pill) that terminate pregnancy. In fact, the report points out that the rates of unplanned pregnancy and abortion fall when contraceptive use rises.

This methodology, known as decades of scientific research, might be considered fringe by some folks.

The write-up on women’s preventive health care services totals more than 200 pages of mind-numbing statistics, references and acronyms. While reading the report, I found myself smiling as though I were watching a beloved Woody Allen film. “This is classic IOM,” I muttered to myself, detecting the signature scent of the institute’s go-to methodology.

This methodology, known as decades of scientific research, might be considered fringe by some folks. But, like a player confident in his game, the report boldly recommends that all contraceptives approved by the Food and Drug Administration—birth control pills, intrauterine devices, etc.—be considered preventive services. The report also recommends that insurance plans cover annual well-woman visits, sexually transmitted infection screening, breast-feeding support, diabetes screening during pregnancy and domestic violence screening—without requiring a co-pay or other out-of-pocket payments.

Despite ongoing efforts to combat unintended pregnancy, the National Survey of Family Growth says about half of the pregnancies in this country are unplanned. Health care providers like me have seen enough women, dressed in flimsy exam gowns and sitting on crinkled butcher paper, wipe away tears of devastation upon learning that their pregnancy test is positive. The public suffers too. A 2011 study from the Brookings Institute estimates unintended pregnancy costs American taxpayers around $11.3 billion a year.

This ignores the serious health risks inherent in pregnancy, such as, oh, I dunno, death.

Opponents argue that pregnancy is not a disease, and therefore its prevention should not be covered. This ignores the serious health risks inherent in pregnancy, such as, oh, I dunno, death. While maternal mortality is relatively rare, all FDA-approved forms of birth control are safer and more cost-effective than pregnancy when used appropriately. Plus, the Institute of Medicine points out that unintended pregnancies suffer higher rates of health problems, such as depression and premature birth.

One enormous benefit of free birth control might stem from increased use of long-acting forms of contraception. These are small devices that are inserted under the skin or into the uterus (like an IUD) and can remain in place for three to 10 years depending on the brand. Women experience a rapid return to baby-making fertility after the device is removed.

Research from the Centers for Disease Control and Prevention shows that these methods are underused in this country, despite the fact that they are now considered a first-line strategy for pregnancy prevention. A 2010 study from the American Journal of Obstetrics and Gynecology shows that when the up-front cost barrier is removed, about two-thirds of women choose this method.

Many of my patients have shared misinformed beliefs with me, such as that condoms are full of holes or birth control causes permanent infertility. Beliefs like these mean free birth control won’t do the trick alone. In fact, the most common reason women say they became pregnant unintentionally is that they believed it wouldn’t happen, according to a study by the CDC. The institute’s report addresses this misinformation by including reproductive education and counseling in its bundle of preventive services.

On one hand, the report outlines a strong vision for the future of women’s health care. The Department of Health and Human Services hit a home run by adopting them. On the other hand, most of these services are already commonplace practice for women who are able to afford them. The unambiguous body of research indicates the recommendations are actually overdue.

When women walk into a health office and sit on that crinkled piece of butcher paper, they should be planning their families and protecting their future health, not experiencing a devastating unplanned pregnancy that could have been prevented. The new rules bring us closer to that elusive reality.

Despite its brilliant name, this column is not intended to prevent, diagnose or treat herpes. Or any other diseases, for that matter.

Whitny Doyle is a family nurse practitioner.

The opinions expressed are solely those of the author.