With the impending demise of Roe v. Wade, making a range of contraceptive options widely accessible is more urgent than ever to help decrease the risk of unplanned pregnancy. When the Affordable Care Act was passed over a decade ago, it brought in a new era of easier access to contraception. The ACA’s provisions specifically aimed to reduce costs and other barriers to birth control options. Yet many people still struggle today to obtain the method they and their doctor have determined is best for them.
First, the good news. By requiring marketplace plans to include key reproductive health-care services, the ACA has significantly increased access to this vital care. According to the National Women’s Law Center, more than 64 million insured women are now covered for at least a dozen forms of FDA-approved contraception at little to no cost thanks to the ACA. This includes coverage for those pricey but long-acting intrauterine devices, which previously cost up to $1,000.
The ACA also mandates maternity care and breastfeeding support for new mothers, as well as preventive screenings for all people to help reduce their risk for diseases such as breast or cervical cancer and HIV/AIDS. Denial of coverage for pre-existing conditions is a thing of the past—a big step forward from the era when a prior cesarean section or incident of domestic violence could cause a person’s insurance costs to skyrocket. The ACA has even helped narrow our country’s appalling racial and ethnic disparities in insurance coverage, although serious gaps remain around maternal health care for people of color, and undocumented people are still excluded from the ACA.
However, the ACA has not reached its full potential to help expand contraceptive use. Despite the law’s requirement of contraceptive coverage without co-pays, some insurance companies and pharmacy benefit managers have gotten away with denying coverage outright, or with tacking on exorbitant co-pays for people who rely on this care. Rather than follow the law and allow individuals to select their preferred contraceptive option, some insurance providers and pharmacy benefit managers also require people to first try other methods—sometimes several—before covering the desired product. Insurers regularly deny coverage for brand-name medications even when no generic equivalent exists. Whether these practices are intentional or simply result from insurers’ failure to establish simple, transparent waiver processes for patients who request an exempt birth control method, the end result is the same: a bar to access.
Roe has collapsed in Texas, and that's just the beginning.
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Fortunately, the federal government has begun to step in. Just last month the Health Resources and Services Administration—the agency whose programs provide health care to those who are geographically isolated, economically disadvantaged, or medically vulnerable—updated its preventive care and screening guidelines for women, infants, children, and adolescents. These guidelines are key to implementing the no-cost contraception rule. This administrative action bolstered existing law and, moreover, provided a much-needed means of addressing the systematic noncompliance by insurers and health plans. It’s a great first step. However, the government must do more to hold insurance companies accountable and to ensure access to the hard-won rights in the ACA.
And last week, more than two dozen senators signed onto a letter they sent to the secretaries of the Health and Human Services (HHS), Labor, and Treasury departments to highlight the need for insurers to comply with the ACA contraceptive mandate. The message was clear and timely: Let’s step up enforcement.
As reproductive health activists have long said, and as the senators’ letter echoed, several federal actions are essential. First, the HHS should move against any insurer that continues to flout ACA requirements. Preventative measures are also needed and may be as simple as creating a transparent, accessible process for patients who are denied their choice of contraceptive method. An electronic portal could give the HHS easy recourse for people who are denied coverage, as well as directly provide the information officials needed for officials to send enforcement letters to bad-actor insurer companies and pharmacy benefit managers. New guidance from federal agencies will go a long way toward ensuring compliance.
The ACA had many holes when Congress passed the legislation over a decade ago, but overall it was cause for celebration. Yet the ACA continues to exclude undocumented people and still contains a ban on most abortion funding. Now, as the ACA enters its tween years, there is much work to be done to advance reproductive health care and prevent unplanned pregnancy. Fortunately, the Biden administration has indicated its commitment to expanding the right to health care and reproductive freedom overall. An easy first step would be to enforce existing laws regulating contraceptive coverage. As our basic rights of whether and when to start a family are on the most endangered list, access to contraception has never been more fundamental.