The controversy over contraception has faded a bit. Congressional Republicans are rethinking efforts to overturn a requirement that would make birth control coverage a mandatory part of health insurance. Rush Limbaugh has stopped talking about the issue, at least for the moment.
But the issue hasn't gone away entirely. The administration is still working on ways to accommodate the wishes of some large religious institutions opposed, for reasons of faith, to sponsoring employee benefits that cover contraception. (On Friday, it unveiled a few options and announced it was seeking public comment on them.) Conservatives, meanwhile, continue to press their case.
With that in mind, let's talk about a conservative argument that isn’t simply about religion or the morality of birth control. It’s the suggestion that birth control coverage simply doesn’t belong in health insurance, because it’s not an expense that all of us should be subsidizing.
Among those making that argument recently was syndicated columnist Mona Charen. After arguing that contraception costs “less than the cost of a weekly trip to Starbucks” and that a variety of programs, public and private, make free contraception available to the poor, Charen draws a distinction between birth control and other types of drugs:
Contraceptives are not a matter of life and death. But even if they were, such as cancer drugs are, is that an argument for forcing insurance companies to provide them free? Why not force free distribution of all medicines? The mandate makes no economic, social or moral sense.
Actually, it makes economic, social and moral sense.
Let’s put aside the question of whether contraception coverage should be “free,” because that’s not really the issue anymore. Republican Senators Roy Blunt and Marco Rubio, along with the Conference of Catholic Bishops, have said they oppose any requirement that forces employers to cover contraception, regardless of whether such coverage requires out-of-pocket expenses.
And, one more time, let’s dispense with this notion that every woman can get birth control for less than the weekly cost of Starbucks. As noted here previously, the cheap drugs at Target, Walmart, and the other big chains are great if you take the standard combination hormonal pills, which combine estrogen and progestin. But some people cannot or should not take those pills. They’re not good for postpartum women who are breast-feeding, for example, and they cause side effects for many others. They may not be as effective, for some women, as methods like intrauterine devices, depo-provera, or surgical sterilization.
How many women fall into those categories? It’s a minority of the population, to be sure. But that’s always the story with health care and health insurance. At any one time, most people don’t require expensive medical care. Only a small number of people do. It’s precisely for the sake of that group – the ones who face high expenses, and could face financial or medical turmoil without assistance – that insurance exists.
Keep in mind that, at some point or another, pretty much everybody falls into that category. Maybe you’re not a woman who needs expensive birth control. You might still be a woman, or a man, who ends up with heart disease. Or allergies. Or a chronic gastro-intestinal problem. Or cancer. Insurance is there to take care of you, so why shouldn’t insurance be there to take care of a woman who needs more expensive forms of contraception?
No, birth control isn’t treatment for an acute condition. It’s routine, preventative care. But that hardly undermines the case for coverage. Think about eye exams for a moment. Or blood pressure checks. Both of these are widely available, for very low cost. In fact, if you do the math, over the course of a year either one would cost less than a year’s supply of even generic hormonal contraception. But insurance typically covers those costs and, under the Affordable Care Act, insurance must cover those costs – because this sort of care keeps people from getting serious medical conditions and, quite possibly, saves money in the long run.
The very same things are true of birth control. Pregnancy is a wonderful thing, but it’s also a serious medical condition that requires serious medical attention. (Those of you unfamiliar with what pregnancy entails might want to consult this page from the American Academy of Family Physicians – or ask a woman who has been pregnant.) Don't forget, too, that some women take contraception to control their menstrual cycles or for reasons that aren’t really related to avoiding pregnancy.
Some critics insist there’s a difference between screening for hypertension or vision problems, on the one hand, and controlling the timing of pregnancy, on the other. Non-procreative sex, they say, is a purely voluntary act, for which others should not have to pay. “No one is touching your birth control, ladies,” conservative writer Amanda Carpenter tweeted on Friday. “We just don’t want to be forced to pay for it.” But, according to statistics from the Guttmacher Institute, 99 percent of women use birth control at times during their reproductive years. Based on that, I think it's safe to assume that non-procreative sex is an activity in which virtually everybody engages, at some point or another, and for which a large majority will need birth control.
And so we’re back to the question that’s always been at the very heart of our health insurance debate: Do we think responsibility for medical expenses should lie primarily with individuals, even if that means some won’t be able to afford it? Or is it a burden we wish to spread more broadly, across society, so that everybody can get the care they need, at a price they can afford?
You know where I stand on that question.
P.S. When the administration announced its options for accommodating religious institutions on Friday, it also released a rule about health plans for college students – and, in so doing, revealed that, for legal reasons, it does not have the authority to regulate all the plans. Sarah Kliff has the story. It doesn't sound like a huge deal, but, as she notes, it's yet another reminder of how complex insurance regulation is in the U.S.
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