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Free Birth Control? Conservatives Say No

The debt ceiling debate has overshadowed some other developments in Washington, among them an announcement on health care reform and family planning. Last week, the Obama Administration announced that it would start requiring insurance plans to cover birth control for free.

It’s part of the Affordable Care Act’s guarantee that insurance companies will cover basic preventative medical services without cost-sharing. And, not surprisingly, the right wing isn’t happy about it.

Here’s an excerpt from a National Review editorial:

….it’s difficult to see what problem this is supposed to address. There is no evidence whatsoever that under current law, women or couples have trouble affording birth control. Condoms are cheap, and many government agencies and private organizations give them away for free. Private insurers cover birth-control pills, albeit with a co-pay, and state Medicaid programs typically cover them for the poor. No research indicates that making birth control even less expensive than it is now will decrease unwanted pregnancies or abortion rates.

No evidence? Really? Let's start with the research about the effects of cost-sharing on medical care, which is about as clear-cut as it gets in this business: When you make people pay more for medical care, they consume less of it. This was the basic insight of the Rand Health Insurance Experiment, which most economists consider the gold standard for this sort of research, and countless studies since then. Conservatives should know this as well as anybody, since the whole point of consumer-directed health care – the approach they generally favor – is to increase cost-sharing so that people will use fewer services and wares, thereby spending less money.

Of course, the problem with higher cost-sharing (and the reason folks like me are wary of it, depending on the details) is that it can discourage use of medical care that’s beneficial. Studies have shown, for example, that seniors react to higher cost-sharing on prescriptions by cutting back on their hypertension medicine. That’s bad medicine, because it increases the likelihood they’ll get a heart attack or stroke. That’s also bad economics, because heart attacks and strokes are incredibly expensive to treat.

Which brings us to the research on birth control and cost-sharing, of which there turns out to be quite a lot.

Probably the best-known study comes from California, which in the 1980s started charging co-payments for family planning services at low-income clinics. Use of those services fell by 22 percent, according to a paper subsequently published in the American Journal of Public Health. The study’s authors determined that likely resulted in around 2,400 unwanted pregnancies and more than $3 million in extra health care spending.

Years later, California introduced a pilot program to offer free family planning services to low-income women not quite poor enough to qualify for Medicaid. Subsequent studies, including another published in the American Journal of Public Health, concluded:

Family PACT contraceptive services provided in fiscal year 1997–1998 are estimated to have reduced the total number of births in California by 7% to 8% in the fiscal year 1998–1999 … The reduction in births also reduced public expenditures for health care, social services, and education for these women and for their children. … averting 108 000 pregnancies saved the federal, state, and local governments more than $500 million at a ratio of $4.48 saved to every dollar expended on family planning services.

A more recent paper on the same project, and published in the journal Health Services Research, concluded that the program significantly reduced not just abortions but also ectopic pregnancies and miscarriages. (Among the reasons: Women who have unintended pregnancies are less likely to get early prenatal care.) And even if cost doesn’t deter women from using birth control altogether, it can deter them from using the most effective types, which are also the most expensive. As a recent essay in the New England Journal of Medicine noted:

Unfortunately, the cost to individuals can be a substantial barrier to the use of highly effective methods. In a nationally representative study conducted in 2004, women of reproductive age who reported that they would have switched contraception methods if it weren't for the cost were more likely to use condoms than more effective contraceptives. Thus, lack of access to the full range of contraceptive options leads to greater use of methods with higher failure rates.

As that essay noted, when Kaiser Permanente Health Plans started waiving cost-sharing for these more expensive forms of birth control, usage more than doubled and, according to estimates, unwanted pregnancies declined.

And that's one reason this regulation could actually make a difference. Although the majority of insurers now cover birth control, they don't always cover all forms and they don't always cover it without significant out-of-pocket expenses, in part because of insufficient state mandates. In a Hart Research survey last year, commissioned by Planned Parenthood, a third of respondents said that they "struggled" with the high cost of birth control and more than half of young adult women said they "experienced a time when they could not afford to use birth control consistently."