Unintended Consequences of Health Reform in Massachusetts: New Barriers to Contraception

One unintended consequence of Massachusetts’ innovative 2007 reform legislation is reduced contraceptive access for low-income women. We can't repeat this mistake nationally.

Clearly the US health care system needs reform.  Massachusetts’ innovative reform legislation
in effect since 2007 provides many lessons that federal policymakers should
heed as they consider models to reform health care across the nation.

Ibis Reproductive Health and the Massachusetts Department of Public
Health Family Planning Program are particularly interested in the impact of
health care reform on contraceptive access for low-income women in
Massachusetts.  The two
organizations embarked on a collaborative research project in late 2008.  Findings from the project highlight the
critical need to pay attention to the architecture of reform to protect access
to contraception for low-income women. 
Focus group discussions with women and interviews with family planning providers
reveal new challenges to accessing and providing care under a health care
system that includes individual insurance mandates and expands access to private
health insurance.

Even with expanded access to health insurance, new barriers to
contraception access have developed. 
Prescription requirements are confusing and inconvenient for some women
who previously accessed their contraception from a family planning clinic.  Providers women like and trust, like
family planning or community health centers, may not be covered under private
insurance plans, and it is difficult for women to identify what contraceptives
are covered and what providers offer covered services. 

Insurance plan information is often confusing and not
user-friendly.  The plan websites
we reviewed did not allow a search for contraception based on common terms like
“the pill” or “the ring” but required the user to know either the brand or
generic name of the method. 

Women in Massachusetts rely on their family planning providers to
help them understand their insurance, translate plan information and mailings,
and complete eligibility paperwork. 
Family planning providers described challenges contracting with the
plans that took part in the state-subsidized scheme, and also faced
administrative burdens with billing and helping their clients understand what
is covered under the new plans.

Women’s health advocates, women themselves, and family planning and
sexual and reproductive health service providers need to pay close attention to
exactly how contraception will be covered and how preventive care in general
will be managed in any national reform plan.  In Massachusetts some new barriers were specific to
contraception services—like some plans not covering services provided by family
planning providers—but others were more about the logistics of the plans and
the eligibility requirements. 
Confusing formularies and women moving on and off the plans due to
erratic employment or life changes like moving or having a baby will affect
more than contraceptive services.   

As Congress continues to debate health care reform, we should ask
whether family planning providers and community health centers are included as
key providers of preventive health care services to ensure women can continue
to access health care with the providers they know and trust.  We should also demand that
contraception be covered at low cost, and that information about the full range
of methods and how they are covered be easily available and
understandable.  We should also
argue for prescription coverage that provides more than one month of medication
at a time—more cycles of hormonal contraception have been show to increase use—as
well as consider innovative strategies for covering the cost of
non-prescriptive contraception methods like condoms.  Another possibility for policymakers to consider is
legislating low copays for contraception in subsidized plans.

Contraception is not only cost-effective but is critical for women to
live the lives they want and protect their health and the health of their
families.  Providing complete
coverage of preventive and women’s health services like contraception should be
part of any national health reform package.