Where's the Birth Control?
Suddenly, healthcare reform seems to be on the mend. The public option returned from the brink of death. The town hall fever broke as inexplicably as it began. And Congress is in the process of remedying discriminatory insurance-company practices based on pre-existing conditions and gender. But just as the prognosis for our healthcare system is beginning to look sunnier, yet another complication has emerged: so far, reform legislation has failed to require insurers to cover some basic preventive services for women, or prevent providers from charging extra for them.
None of the bills emerging from the House and Senate require insurers to cover all the elements of a standard gynecological "well visit," leaving essential care such as pelvic exams, domestic violence screening, counseling about sexually transmitted diseases, and, perhaps most startlingly, the provision of birth control off the list of basic benefits all insurers must cover. Nor are these services protected from "cost sharing," which means that, depending on what's in the bill that emerges from the Senate, and, later, the contents of a final bill, women could wind up having to pay for some of these services out of their own pockets. So far, mammograms and Pap tests are covered in every version of the legislation.
Granted, Congress can't--and shouldn't--get into the business of spelling out every possible cause for a trip to the doctor. No one wants the process to collapse under a mountain of requests from special interest groups à la the Clinton mess in 1993. But women, half of all adult patients, are not a special interest group. And since both the House and Senate bills include lists of specific services that must be covered by health insurance companies and be provided without asking patients for additional money, it's hard to understand why all the services provided in a basic well-woman visit to the gynecologist isn't on them along with maternity care, newborn care, pediatric dental and vision services, and substance use disorder services.
The fault for the initial omission can be laid at the feet of Democrats, who shied away from the issue, not wanting to invite controversy, according to women's health advocates who tried unsuccessfully to get women's preventive health care included in the basic benefits package. Some of the concern had to do with cost. Adding any required service to the basic benefits package would mean the Congressional Budget Office would give the bill a higher score, or price tag, leaving it more vulnerable to attack by budget hawks. But another part of the problem clearly stems from the fact that women's bodies have become political lightening rods, even when abortion is not the issue.
Consider what happened when the subject of women's preventive healthcare services came up in the Senate Health, Education, Labor and Pensions Committee (HELP) in July, after the minimum benefits package had already been determined. Because some essential care for women wasn't included in the list, HELP committee member Senator Barbara Mikulski proposed an amendment that would require the Health Resources and Services Administration (HRSA) to stipulate that basic women's health services would be covered. The language said nothing about abortion, referring only to "preventive care and screenings."
Yet the voting on the amendment went exactly along pro- and anti-choice lines. The amendment passed by just one vote, with all the committee's Republicans as well as Pennsylvania Senator Robert Casey, an anti-abortion Democrat, voting against it. The committee's discussion of the amendment was dominated by Republicans' worry about the possibility of government money winding up in the hands of Planned Parenthood. Since there is no similar language included in the just-released House bill, the only hope for requiring full coverage for these essential services now lies with the Senate.
While some within the anti-abortion movement have long opposed birth control, there is still widespread support for it among the general public, with virtually all women of childbearing age who have had sex using contraception. So why would senators treat birth control and other basic women's health services as a proxy for abortion? "People equate family planning services with Planned Parenthood, and they equate Planned Parenthood with abortion," says Adam Sonfield, an expert on funding for reproductive health services at the Guttmacher Institute. The senators who turned Mikulski's language into a referendum on abortion "either misunderstood or purposely distorted the amendment."
Either way, the irony of letting anti-abortion sentiment undercut the coverage of birth control is that it will likely lead to more abortions. "If women can't get this kind of primary care, there are three clear outcomes: cancer, abortions and infertility," says Anne Davis, medical director of Physicians for Reproductive Choice and Health, and a practicing Ob/Gyn in New York City. Davis cites the facts that untreated sexually transmitted infections can lead to infertility, and that pelvic exams help diagnose cervical cancers. As for the importance of covering--and not requiring women to kick in additional money for--birth control, Davis says, "It's fundamental primary preventive care. So if we don't do this, we're causing a lot of abortions."
Still, some Democrats involved in the health reform sausage-making process counsel patience. Noting that both Pap smears and mammograms should be covered by a reform bill, Senator Al Franken said, "There's more we need to do for women's health, but this is a huge step forward for American women, many of whom don't get these recommended screenings right now. What we pass may not be perfect, but it will make progress in improving the lives and health of women."
Yet, before we resign ourselves to a very imperfect health reform bill, it's worth reminding lawmakers that women's health extends far beyond abortion. And while those who make our laws may fear the consequences of taking a stand for basic services for this half of the population, the cost of not doing it, both in terms of health and politics, is sure to be far greater.