Six years ago, Karen Clayton, a manager at a hospital in Chicago, thought about getting an IUD. She had had bad reactions to hormonal birth control in the past and had decided to stop using it, but she had recently entered a new relationship and was under the impression that her insurance would cover ParaGard, a copper IUD that does not release hormones. When she went to the doctor’s office, however, she was told that the device would actually cost $300 or $400, she recalls — more than she could afford at the time.
One month later, Clayton found out she was pregnant. She returned to the same doctor. “I could tell she felt badly” after seeing her so recently, Clayton remembered. They discussed her options and Clayton went to a Planned Parenthood center, where she paid for an abortion.
“If [the IUD] had been available, covered, even cheaper,” Clayton said, “I definitely wouldn’t have had a pregnancy to terminate.” When she found out a few years later that the IUD was now fully covered by her insurance because of the Affordable Care Act (ACA), she got one immediately.
Clayton is not the only woman who has new contraceptive choices available to her under Obamacare. The contraceptive mandate of the ACA, which went into effect in 2012, stated that all FDA-approved contraceptive methods would be fully covered by health insurance plans (except grandfathered plans and those provided by certain religious employers), meaning that for millions of women, cost is no longer an obstacle to accessing some of the most effective forms of birth control. Experts are hopeful that making IUDs and implants available without out-of-pocket cost will increase their use, although barriers including gaps in coverage and lack of awareness remain.
The IUD, or intrauterine device, is a small device that is inserted into the uterus and provides protection against pregnancy for between three and 12 years. There are currently three brands of IUDs on the market in the U.S.: Two are plastic and release hormones and a third is copper and does not. Both the IUD and the birth control implant, which is typically inserted in the upper arm and prevents pregnancy for up to three years, are kinds of long-acting reversible contraception (LARC), which tends to be extremely reliable: The IUD has a failure rate of less than 1 percent and is considered to be 45 times more effective than the pill and 90 times more effective than male condoms based on typical use. But without the coverage provided by the contraceptive mandate, these methods of birth control have been out of reach for many women because of their exorbitant out-of-pocket cost, often as high as $1,000. Without insurance coverage, getting an implant or IUD could cost a month’s salary for a woman working full time at minimum wage, according to the Guttmacher Institute, a nonprofit that advocates for reproductive health.
Until recently, LARCs also suffered from a bad reputation. IUD use had declined after the Dalkon Shield scandal that started in the 1970s, when a poorly designed IUD caused at least 18 deaths. Thousands of women filed suit against manufacturer A.H. Robins, citing septic abortions and emergency hysterectomies. The dangers of the Dalkon Shield loom large in many women’s perceptions of IUDs. “Older women remember that,” said Carol Weisman, a public health professor at the Pennsylvania State University College of Medicine. “Younger women have heard about it, and they don’t necessarily have good information about the IUDs available.”
But in the past few years, professional organizations and medical experts have encouraged both providers and patients to consider the benefits of these contraceptives. “Within the reproductive health community since about 2006, 2007, there’s been a lot of focus in trying to re-educate providers about IUDs and implants,” said Kirsten Thompson, project director of the LARC Project at the University of California, San Francisco’s Bixby Center for Global Reproductive Health.
There have also been changes in the way these contraceptives are used. In the past, IUDs were mostly prescribed to women who had already had at least one child, according to Adam Sonfield, a senior public policy associate at the Guttmacher Institute. But doctors have begun prescribing the devices for women who’ve never had children and younger women as well. This past September, the American Academy of Pediatrics recommended IUDs and implants as the best form of birth control for teenagers. “And also there’s been a lot of marketing to younger women,” said Alina Salganicoff, vice president and director of women’s health policy at the Kaiser Family Foundation. She points in particular to Bayer’s newest IUD, Skyla, which was approved by the FDA in 2013. The product’s website features young women with musical instruments or cameras next to the slogan, “This is my baby right now.”
As a result of these medical and cultural changes, IUD use was already increasing in the United States before Obamacare made it and other contraception essentially free. According to the CDC, the use of LARCs increased almost fivefold between 2002 and 2013 among women ages 15 to 44. A study published by the CDC in April found that the percentage of women selecting LARCs at Title X family planning clinics, which offer family planning services to low-income or uninsured individuals, had increased to 7.1 percent in 2013 from 0.4 percent in 2005, a sign that low-income women are opting for IUDs and implants more often. And reduced out-of-pocket costs may further increase the prevalence of these contraceptives.
There is no comprehensive data yet for how much LARC use may have increased since the ACA. The CDC data only goes up to 2013, which is after the ACA was enacted but mostly before key provisions took effect. (The contraceptive mandate did not kick in for most plans until January 2013 or later, according to Sonfield, and the Medicaid expansion and the opening of new health insurance marketplaces only occurred in 2014 ).
According to the Guttmacher Institute, the percentage of privately insured women who paid nothing out of pocket for the IUD has already risen. In a study published last September, researchers found that the percentage of women getting an IUD who had not paid for the device out of pocket increased to 62 percent from 45 percent. (There are no corresponding numbers for the contraceptive implant because the pool of those using it was too small to be a reliable sample.)
Some pharmaceutical companies have seen a change in the use of their contraceptives. From March through August 2013, Bayer ran a print advertising campaign highlighting the fact that under the ACA, patients’ insurance plans might cover the full cost of Mirena, its first IUD, and throughout 2013 it targeted consumers with online banner ads on a similar theme, though the company would not release American sales figures for its products. A spokeswoman for ParaGard, the copper IUD, said that insertions in the U.S. had been increasing since 2012. (A representative from Merck, which creates the two FDA-approved birth control implants, said that none of Merck’s advertising efforts highlighted the contraceptive mandate and that it would not release sales figures.)
Studies have shown that when the cost goes down, the use of LARCs goes up. In a study published in 2011, researchers tracked women who had requested IUDs and were then told about the out-of-pocket costs: 79 percent of the women who had IUDs placed had a co-pay of $50 or less. “Women requesting an IUD for contraception are significantly more likely to have an IUD placed when out-of-pocket expense is less than $50,” the study concluded. When the Kaiser Foundation Health Plan in California changed its policy in 2002 to include 100 percent coverage for what it deemed the most effective forms of contraception, it found that in the next two years, there was an increase in presumed usage rate across all types of birth control studied, but none shot up more dramatically than IUDs.
Combined with counseling, the elimination of out-of-pocket costs can have a striking effect on the use of LARCs. Researchers often point to the CHOICE Project in St. Louis, a study that followed 9,256 St. Louis-area women between the ages of 14 and 45. Each woman was offered the reversible contraceptive of her choice without cost for two or three years and was allowed to change methods as often as she wished. The women were counseled on the methods available and specifically told that the IUD and implant were extremely effective. Seventy-five percent of them chose a LARC method. A study of the first 5,087 participants found that the women who chose these methods had extremely high continuation rates, indicating that they were satisfied with the devices: 88 percent of women who chose the hormonal IUD, 84 percent of the copper IUD users and 83 percent of implant users continued using the same method 12 months later.
Yet barriers remain for some women seeking to use these methods. For one thing, even insured women do not have access to all methods. “Grandfathered” plans — plans that existed on or before March 23, 2010 — are exempt from the contraceptive mandate. According the Kaiser Family Foundation, 26 percent of covered workers were covered by grandfathered plans as of September 2014, although their number is decreasing. A recent report, also published by the Kaiser Family Foundation, found that even those on non-grandfathered plans did not always have access to the full range of available birth control options. The researchers surveyed 20 insurance carriers in five states and found that two insurers did not cover the implant at all and only 10 covered all three FDA-approved IUDs with no limitations or cost-sharing (they were unable to ascertain coverage from four carriers). Further, some employers may be exempt from the contraceptive mandate after last year’s Hobby Lobby case, in which the Supreme Court ruled that certain corporations with religious owners did not have to pay for insurance coverage of contraceptives.
Cost is not the only obstacle. “There is still a lack of awareness about the current LARCs available,” said Weisman, the Penn State professor. The location of clinics and the items they keep in stock can also pose barriers. It is easy for a primary care physician to write a prescription for oral contraceptives, Weisman said. “But most are not going to provide IUDs and implants” during an office visit. Even if a woman is referred to a gynecologist who can give her an IUD or implant, it’s not always possible to get a same-day insertion. These timeliness issues can also be a factor for women who must take time off work or make a long trip to a doctor’s office for care. “There’s an interest in the field in smoothing that transition,” Weisman said.
While health care providers are excited about the prospect of increased LARC use thanks to the ACA, many caution that it is important to realize that effectiveness is not the only criterion that women consider when using contraception. “LARCs are not going to be appropriate for all women. We do expect to see an increase in their use, and that would be terrific,” Weisman said. But, she added, “we can’t expect to see a majority of women using them.”