Dozens crowded into the National Academies building in a snow-blanketed Washington last Wednesday morning to attend a meeting of the committee charged with making recommendations as to whether birth control and other women's health services will be considered preventive healthcare—and thus available without a co-pay to enrollees in health insurance plans, including those offered through the Affordable Care Act. Among committee members—respected physicians and public health experts appointed by the Institute of Medicine—there seems to be little doubt about the preventive benefits of contraception, which is used by more than 38 million American women to avert countless unwanted pregnancies and abortions.
Yet, in this uncertain moment when the health reform law itself is under attack, the political question of whether contraception counts as prevention remains open—and subject to potentially long and fiery debate. While birth control has always been somewhat contentious, it has long been the more politically palatable cousin of abortion, with a constituency that included some antichoice members of Congress who supported it as a way to decrease abortions. But, healthcare reform has created a new battleground for the issue, and, with more conservatives now in Congress and state governments, birth control is shaping up to be a divisive issue in the coming legislative session.
After the wrangling over what would be included in the final bill, prochoice advocates lost big: in order to obtain insurance coverage for abortion, policy-holders will have to pay for it separately. But a provision to the healthcare reform law added by Senator Barbara Mikulski that required all new health insurance plans to cover preventive services for women with no out-of-pocket cost to patients survived. The problem is that the law doesn't specify exactly which services should be on the list along with pap smears and other less controversial forms of health counseling and disease prevention. The other problem is that, after the fight over abortion coverage almost derailed healthcare reform, many politicians are now extremely skittish about coverage related to sex and women's bodies, fearing it will damage public receptivity to the bill.
The Obama administration is moving cautiously on the issue. The Department of Health and Human Services appointed the committee to iron out the details of preventive services for women, giving it until August to come up with a final list. The committee is also discussing allowing insurers a grace period after the new rules are issued before they have to adhere to them. Douglas Laube, a veteran ob-gyn and chair of the board of Physicians for Reproductive Choice and Health, who attended a fall meeting with White House staff to discuss the issue, described members of the administration as appreciative of the importance of birth control—but also worried. "Nobody in that room disagreed," said Laube. "It all had to do with the potential political fallout."
Wednesday's meeting—the committee's second—was attended by a handful of antichoice activists who spoke during the open comment period. Many of them, including representatives from the US Conference of Catholic Bishops, argued that birth control isn't prevention because pregnancy isn't a disease. Mirroring the strategy abortion opponents took with health reform, several called for creating a pool of insurers who don't offer contraception— "a virtuous option in health plans," as Michael O'Dea, executive director of the Christus Medicus Foundation in Michigan, a nonprofit devoted to "Christ-centered health care," put it. Several others argued that emergency contraception in particular shouldn't be covered, since they see it as a form of abortion.
Meanwhile, Tuesday night, Representative Mike Pence introduced legislation into the House that would block federal funding to organizations that perform abortions, so that groups such as Planned Parenthood would no longer receive Title X money for family planning. Pence, whose bill has 122 co-sponsors, unsuccessfully introduced similar legislation in 2007 and 2009. This time, though, with a new level of post-election hostility toward contraception, his luck could change.
"This Congress has the worst composition we've ever seen," says Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association. "The numbers are worse by dozens. There are more Republicans and more markedly conservative members and, in their minds, abortion and family planning are treated the same." While some of the moderates have been voted out, others may be under intense pressure to turn their backs on family planning. Coleman cites Fred Upton as a prime example. Upton, the new chair of the House Energy and Commerce Committee, has voted against Pence's bill in the past. "This time, we believe he won't vote consistent with his record," says Coleman. "He's moved into a more conservative frame to be chair of his committee."
Indeed, while Coleman's organization used to keep its own (higher) count of Congress members' support for family planning services—including support for Title X, comprehensive sex education, and international family planning funding—apart from abortion, this year the group judged the breakdowns to be so similar that they're simply using prochoice organizations' tallies. If anti-contraception sentiment is truly rivaling that against abortion—something we can't know until a vote comes up on the issue—the outlook is grim. According to an analysis done by NARAL , there are antichoice majorities in both the House and the Senate.
Even with Pence's bill back on the table and the tide seemingly turning against contraception in Washington, Cecile Richards, president of the Planned Parenthood Action Fund, sees state legislatures as "the more insidious threat." Eight new antichoice governors took office, and now fully fifteen state governments are antichoice—a shift that may have devastating consequences for state family planning funding.
"Almost every state is dealing with significant budget issues and decisions are being made about cutting programs," says Richards. "Given the rightward tilt of a lot of state legislatures and very legitimate budget issues, family planning is going to be at risk in a lot of states."
Sensing the political vulnerability of birth control, Planned Parenthood, the largest family planning provider in the country, set out to document its widespread public support. In October, the organization launched a national campaign, complete with an online petition and Gossip Girl–inspired video featuring someone dancing around New York City dressed as a pack of birth control pills.
The group also released the results of poll of 802 registered voters showing that 75 percent supported greater access to birth control and that 71 percent "disagree with cutting federal funding for preventive health services at Planned Parenthood health centers," an outcome that could be achieved either by the Pence bill or if the administration decides not to deem birth control preventive care.
It's hard to square such numbers with the current political reality: mounting hostility toward birth control in Congress, including a new House speaker who has come out against it. State houses where family planning funds are on the chopping block. And a prolonged debate over something as seemingly simple as whether contraception constitutes prevention. That, according to Planned Parenthood's Richards, is the point.
"When you look at the general public, this is such a no brainer," says Richards. "Our goal is to make sure Congress understands what a common-sense policy this would be."