Obamacare was supposed to make all birth control free. As a doctor, I see it’s not happening.

All contraceptives are to be covered without a copay.

That was the promise of the Affordable Care Act when it passed in 2010. The specific provision regarding contraceptive coverage took effect in 2013.

Advocates and policymakers repeat this assertion all the time. But I know, as many practicing physicians do, that it is not as simple as that.

I currently work primarily with low-income patients — now at a clinic in Indianapolis, and previously at one in California. I am reminded every day how hard it is for my patients to obtain birth control. Too often, I have patients return or call my office telling me that their insurance didn’t cover the birth control I prescribed, that there was a copay they could not afford or some roadblock has appeared that effectively denied them the method of contraception we had discussed.

Sometimes I will get a call from a pharmacy asking to change the birth control I prescribed — and that’s if the pharmacy happens to get ahold of me during business hours. Sometimes I will get a fax requesting insurance-specific paperwork to be completed to justify why a method was chosen over another.

But most frequently, it isn’t until the patient returns to tell me what happens that I find out she wasn’t able to get her birth control. This means she never started to use it and has been at risk for an unplanned pregnancy for the days, weeks, and months that have passed since I last saw her.

Low-income patients face multiple obstacles filling birth control prescriptions

There is one patient I remember clearly who wanted to begin taking oral contraceptive pills. We discussed the different types of pills and how we would start with a low-dose estrogen pill given that this was her first time using contraception.

I saw her during a follow-up a month later and learned that she hadn’t received the prescription that I sent to the pharmacy. When I called the pharmacy to figure out what happened, the pharmacist explained that the insurance company formulary didn’t cover the specific contraception I had prescribed. The health plan did cover one with a slightly higher dose of estrogen, and the pharmacy had tried to contact our office to substitute the prescription but had been unsuccessful in reaching us.

These types of administrative barriers to patients obtaining contraception are not unique.

In 2015, the Kaiser Foundation released a report documenting this same issue in five states around the United States. After interviewing staff at 20 different insurance companies, they too found a wide variety of contraceptive coverages were in place — some with cost sharing and some without. They also noted the difficulty in obtaining this information for the report and the fact that it was not always easy to find, readily available, or even known by the insurance company employees. This highlights again how challenging this is for a consumer or clinician.

Is the law being broken here? Not exactly. It is true that Obamacare requires insurance companies to cover the 18 FDA-approved types of contraception. But this means that coverage must include one method, at a minimum, from every category of contraception.

For instance, let’s consider the combined oral contraceptive pills used by millions of women in the United States. There are three categories of oral contraceptives: progestin only, combined, and extended use. While there are slightly over 100 different types of oral contraceptive pills on the market, an insurance company only has to provide coverage for one of them in each category.

Good luck remembering which one each individual insurance company has committed to covering when you see a patient.

Even worse, insurance companies can change what drugs they cover without notice. The electronic medical record systems I use rarely pick up this information in real time when prescribing medication for patients. It’s also possible that a pharmacy may not stock the specific form of contraceptive pill, even if it is covered by the patient’s insurance.

How insurance plans can still deny birth control coverage under Obamacare

Then there’s something called “reasonable medical management,” which allows insurance companies to require patients to try a cheaper contraceptive before moving on to a more expensive one. For example, if a patient would like to use a contraceptive patch, an insurance company can require a prior authorization clarifying why an oral contraceptive isn’t acceptable to try first.

This became an issue with a patient of mine who wanted to start using birth control. She was an adolescent and an athlete with a busy schedule. After discussing various options, she decided to try the contraceptive patch. This method would give her the contraceptive coverage she needed and would only require remembering to change it once a week. Many weeks passed until I actually saw the fax from the pharmacy: The insurance plan had denied the contraceptive patch because a contraceptive pill hadn’t been tried first.

The insurance company was requesting documentation from me as to why this patient needed this particular method of birth control over other daily methods. When I finally got in touch with the patient, she explained that she didn’t want to call our office about what had happened because she was worried her mother would find out what had been prescribed.

In May 2015, new federal guidelines began to restrict the use of “reasonable medical management” to within a method category. In other words, they can restrict different contraceptive pills but can’t require that you try a contraceptive pill before you try a contraceptive patch. That should go into effect over the next year.

However, insurance companies can still require a “waiver” or “exception” process that will involve some sort of paperwork completed by physicians to document why a certain contraception has been chosen after seeing the patient. This required paperwork will be added to the already busy clinical practice and is often not known to be required until after the patient goes to the pharmacy for the prescription.

What’s more, the Kaiser report mentioned earlier noted that none of the insurance companies interviewed had a specific appeal process set up for denials of coverage pertaining to preventive services. Instead, consumers go through the generic appeal process the insurance company has in place, which can often take weeks.

All of these barriers are legal and have been documented by various advocacy organizations. It is also important to note that the ACA regulations on contraceptive coverage only apply to Medicaid expansion programs and private insurance. Traditional Medicaid members, those who qualified for Medicaid before the expansion, are not guaranteed the “all-inclusive” contraceptive coverage touted recently.

Most traditional Medicaid programs do provide some contraceptives without additional costs, but the formularies they use to define coverage of certain types of contraception can vary from state to state and can change frequently.

Less access to birth control means more unintended pregnancies

What is most frustrating about the current state of contraceptive coverage is that it’s hard to determine who, if anyone, benefits from this restricted access. Unplanned pregnancies are very expensive not only to society but also to insurance companies. The cost of paying for contraception for a year (or even 10 years) is significantly cheaper than paying for prenatal care and subsequent labor and delivery. The estimated costs of unplanned teenage pregnancies in the United States each year is $9.4 billion.

Evidence exists showing that removing barriers to contraceptive use is effective and leads to a sharp decline in unplanned pregnancy, birth, and abortion rates. Consider the Choice Project in St. Louis and the Colorado Family Planning Initiative, two large-scale programs focused on providing the most efficacious forms of contraception, long-acting reversible contraception (LARC) like IUDs and implants. Both of these programs worked on removing barriers to contraception access for those at greatest risk for unplanned pregnancy — low-income women and adolescents.

They simply gave patients contraceptive options (emphasizing efficacy) and assured them they would leave with the chosen contraceptive method that day, free of charge. They required no prescriptions or trip to the pharmacy. They demanded no copays. No appointment to come back for placement was necessary, and no prior authorization was demanded required for a device.

As a result of this new model in access, study subjects overwhelmingly chose more efficacious forms of contraception. Both programs showed astonishing results cutting rates of unplanned pregnancy, births, and abortion rates by double digits.

Results like these should be celebrated by everyone, regardless of where they are on the political spectrum, because they are good for patients and for society. Improved outcomes were not a result of a new form of contraception, a medical breakthrough, or a change in behavior. All that was necessary was the removal of barriers to contraception coverage. The ACA may have intended to do that in theory, but in practice it is falling short.

Tracey Wilkinson is an assistant professor of pediatrics at the Indiana University School of Medicine.

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