Why Doesn't Health Care Cover Birth Control?

Nancy Pelosi made her wrenching choice between the health reform bill and abortion rights, and—unless Obama works some magic soon—American women will have to live with it. Since the House bill passed with just two votes to spare, the anti-abortion language in the Stupak amendment may have been essential for passing it. (The Catholic leadership, which had lobbied heavily against abortion funding all summer, gambled, correctly, that, despite Pelosi’s commitment to abortion rights, she wouldn’t abandon the bill on principle. The same, it should be noted, cannot be said of the bishops, who were willing to kill the whole deal—pediatric services and all—if all of their own demands were not met.)

Abortion, it seems, was lost to political horse-trading. But there are also deeper forces at work that will continue to affect the 10 million women who are expected to participate in a health care exchange—an infuriating irrationality that taints not just abortion, but many other health issues that are perceived to be connected to women’s sexuality.

The best example is birth control, which was also recently thrown under the health-reform train. So far, none of the three reform bills has required insurers to cover contraception, although it is almost universally used by heterosexually active women. Other preventive services, such as some counseling about sexually transmitted diseases and pelvic exams, didn’t make the cut, either. Nor have the bills protected these services from “cost sharing,” which means that women may well end up paying for much of their birth control out of their own pockets.

Women’s health advocates reported that some Democrats cited a fear of igniting controversy when asked to insert birth control and other preventive services for women into the minimum benefits package. What’s the controversy, exactly? It seems birth control has become a suddenly loaded political issue, a toxic sister to abortion, somehow resonant of irresponsible sex and women’s bodies. And this time around, no one wanted reform to collapse under the weight of special interest groups’ requests, as the Clinton effort did in 1993. Ultimately, people fell back on budget concerns. Adding to the list of services insurers must offer would have given the bill a higher score from the Congressional Budget Office—and made it more vulnerable to attack from budget hawks.

But there was certainly no medical justification for excluding contraception from a list of services to be covered without co-payment, which included newborn care and pediatric vision services. Surely fertile women don’t represent a “special interest group,” since the overwhelming majority of women—including more than 80 percent of Catholics—use birth control. For most, the need is chronic, which helps explain the fact that, even though most plans now cover contraception to some degree, women already pay more than men out of their own pockets for health care. To wind up with two children (roughly the average family size), most women need to use contraception for about three decades.

Most doctors understand the importance of birth control: Women who use it have lower rates of infant and child mortality, more time to nurse their children, and a smaller likelihood of high-risk pregnancies and anemia. More than 38 million women are currently using some form of it, according to the Guttmacher Institute, which conducts research on reproductive health. And almost all sexually active women use birth control at some point.

Yet despite its widespread use and acceptance, lawmakers don’t see birth control as the fact of life that it is. Even though politicians are—or, at least, presumably were at some point—regular people, they pretend that something most women have used as a matter of course is a moral issue, and a politically radioactive one at that.

If you ask a pro-life activist what exactly is objectionable about birth control, you’re likely to launch a discussion about when life begins. That’s because much of the opposition to contraception that’s sprung up over the last decade or so has been hitched to the idea that specific methods are tantamount to abortion. In this mindset, the IUD, oral contraception, and the “morning-after” pill are essentially abortifacients, since they may prevent the implantation of an already-fertilized egg—a life, in their view.

Yet this tight logic hasn’t survived the leap from far-right circles to mainstream politics. For one, it leaves open the glaring question of why pro-lifers have little interest in other birth-control methods that can prevent abortions. You’d expect anyone who’s truly concerned about protecting life to be interested in supporting at least the forms of birth control that work before an egg is fertilized. Yet you rarely hear pro-lifers promoting condoms or diaphragms, which are among the surest bets in preventing abortions. And, indeed, there was no distinction made among birth control methods in public discussions around health reform.

In truth, a broader sentiment seems to be fueling the discomfort with contraception. Perhaps the American Life League gets to the heart of it best, noting on its website that birth control leads to “a state of mind that treats sexual activity as if it has nothing to do with babies”—i.e., to put it in plain terms, promiscuity. Birth control somehow shades into abortion, and together both lead women down the path to immorality.

Few in Washington or elsewhere would cop to such plainly sexist views. Once it’s actually put into words, the blanket condemnation of all sex without the intention of making babies is obviously out of step with the way most people think and live. It’s arguably even more retrograde than the idea that certain methods of birth control are equivalent to abortion. Yet in July, when senators debated an amendment put forward by Barbara Mikulski proposing full coverage of birth control and other preventive women’s health services, the conversation focused on Planned Parenthood and abortion, despite the fact that neither was mentioned in the amendment.

It’s the rare—and almost always female—politician who’s willing to brave these irrational currents to fight for birth control. Mikulski’s amendment is now the only remaining hope of getting birth control completely covered and paid for in the final health-reform bill.

The majority of politicians seem intent on steering clear of the whole tawdry mess. Yet it’s worth remarking that even as they give off an air of quiet disapproval, most of these lawmakers somehow do not have huge broods of children themselves. If the subject of birth control comes up, they often respond—or, rather, don’t—with the kind of wide-eyed panic you might expect from someone accused of playing footsy with another man in an airport bathroom. When George W. Bush was asked whether he supported the use of contraception, for instance, the usually garrulous father of two stayed mum.

Women are now falling into the silence left by these hypocritical and terrified politicians. Though lawmakers have treated birth control and abortion as abstract matters of values, the consequences of their heady decisions for women will be quite real. The consequences will be harshest for the middle- and low-income women most likely to participate in a health exchange. If they have to pay for part or all of the cost of birth control themselves, women will be less likely to get it. Some will get pregnant. And virtually all of the women who want abortions will be unable to get them covered through our new national health plan.