Health Policy

Contraceptive Conundrum

Uncertainty about the future of the Affordable Care Act has women seeking longer-term birth control

Contraceptive Conundrum

5 Minute Read

A few weeks after Inauguration Day, Megan Toomey paid a visit to the doctor. She left the office that afternoon with a newly inserted IUD and peace of mind. Toomey is part of a growing group of women following the 2016 election who are opting to have IUDs placed due to uncertainty about the future of the Affordable Care Act (ACA) and the comprehensive contraceptive coverage it provides.

In the nearly seven years since President Barack Obama enacted the ACA, women have enjoyed free or greatly reduced access to a variety of contraceptives, thanks to a provision mandating coverage of “all Food and Drug Administration approved contraceptive methods … for all women with reproductive capacity.” During a vote just days before the Jan. 20 inauguration, however, the Senate took a major step toward repealing the ACA while simultaneously opting not to approve an amendment to continue requiring contraceptive coverage even if other parts of the bill are repealed.

For many women, this further cemented their fear that access to birth control could soon be limited. Some took to social media to voice concerns and urge women to take stock of their reproductive futures. And for others, it was the final push needed to made an appointment to have an IUD inserted.

“I chose the IUD, and Mirena specifically, because it lasts for five years,” said Toomey, a Houston mother with a 1-year-old. “It gives me comfort to know that by the time I need to make another decision about birth control, our political climate will hopefully be different.”

Toomey added that she had never had an IUD placed before because she was concerned about the pain of insertion, but decided the financial benefits of the IUD now outweighed the possible negative aspects. The process did not require a copay.

Had it not been covered, “paying the $700 for the IUD and $300 for insertion would not have been manageable,” she said.

Analysts for electronic health record company athenahealth studied 1 million patient visits to the 85,000 providers in their network and discovered that between October and December 2016, visits to obtain IUDs rose 19 percent over the same time period the previous year. The researchers say this is the first time in five years that IUD requests increased in both November and December.

In the Houston region, Planned Parenthood Gulf Coast has seen an even greater spike in IUD requests in recent months. From Nov. 1, 2016, through Jan. 31, 2017, providers at Planned Parenthood Gulf Coast inserted 656 IUDs. In the same time period the previous year, the organization placed 381 IUDs. This amounts to a 72 percent increase.

Beyond data, Laura Thomas, senior director of clinical services at Planned Parenthood Gulf Coast, said she has noticed a change in the attitudes of the women she treats. Typical reasons she hears for choosing IUDs include not wanting to have to take a pill every day, avoiding hormonal birth control or not wanting to have a period every month. Lately, she’s noticing something new.

“I’ve been hearing different things from patients than I’ve ever heard before,” said Thomas, who has worked for the organization since 2009. “Even just yesterday, when I asked a patient, ‘Why did you choose this method?’ She said, ‘Because I’m worried I’m not going to have coverage.’”

For women uncertain about future access to contraceptives or even health insurance, IUDs are appealing because they are designed to prevent pregnancy for at least three and up to 10 years, depending on the type.

IUDs are T-shaped devices inserted into the uterus. Copper IUDs, like ParaGard, do not have any hormonal medication in them, while IUDs like Mirena, Skyla and Liletta do.

The first way IUDs work is by preventing sperm from meeting an egg. The copper IUD releases copper ions, which essentially work as a spermicide. Hormonal IUDs release progestin, which increases production of cervical mucus. This essentially works as a barrier method, making it more difficult for sperm to pass through the cervical canal.

“If you have a really determined sperm that manages to make it all the way through anyway, because that T is sitting there, it also makes it more difficult for the sperm to move throughout the uterus and enter the fallopian tubes where eggs are normally fertilized,” said Jennifer Bump, M.D., associate professor of obstetrics and gynecology at Baylor College of Medicine. “If both of those mechanisms fail and the sperm manages to fertilize an egg, it also makes it difficult for the egg to implant into the uterine lining.”

IUD failure rates are under one percent, which is comparable to both male and female sterilization, according to the Centers for Disease Control and Prevention.

While insurance providers are mandated under the ACA to offer coverage for contraceptives, the IUD is a cost-effective and long-lasting choice. If that mandate is eliminated, the price of an IUD would be prohibitively expensive for many women.

“The IUD is a big upfront cost. It’s less expensive overall if you use it the full five or 10 years, but a lot of women can’t afford to pay $900 all at once,” Bump said. “They could afford a $30-dollar a month pill, but it’s more prone to error. It’s something you have to physically do every day.”

The proposed dismantling of the Affordable Care Act is adding a lot of stress to a decision providers say should be based on a patient’s lifestyle and health history rather than finances and accessibility. And even greater than the full cost of an IUD is the price of an unplanned pregnancy, the rate of which has dropped in the years since contraceptive coverage was expanded, according to the Guttmacher Institute.

“Looked at from solely a cost perspective, it’s much more expensive for us as a society to pay for uninsured women to have babies than it is to pay for birth control,” Bump said.

An increase in IUD implantation is not necessarily a bad thing, Thomas noted, given their safety and effectiveness. The emotional toll health coverage turmoil has on women, however, is concerning for the health care providers who counsel them.

“I worry because patients seem to have this level of anxiety and fear that I’ve not seen before,” Thomas said. “They’re just really worried they’re not going to have access.”

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