The Agenda

Is There a Compelling Public-Health Case for the HHS Mandate? Not Really

In this week’s Hobby Lobby decision, the Court decided that it didn’t need to question whether the HHS mandate serves a compelling government interest in order to rule against it. But if it had considered the question, it’s far from an open-and-shut case that HHS was justified in including contraception under its “preventive services” mandate — under the assumption that reducing the rate of unintended pregnancies is a compelling state interest, and that free contraception is the right way to get there.

The first assumption is easily defendable. From an economic standpoint, reducing unintended pregnancies is linked to more women in the workforce and significant savings for taxpayers. Further, allowing women to better control when or if they conceive leads to higher levels of educational attainment, happier mothers, and healthier children.

The second assumption is much more problematic. Contrary to what you might think, there is little evidence to suggest free contraceptives necessarily reduce the rate of unintended pregnancy.

In 2012, the widely publicized Contraceptive CHOICE Project study published in Obstetrics and Gynecology showed strong links between a free-contraception program and reductions in abortions and teen pregnancy. However, as NRO’s Michael New points out, the study is riddled problems: It has no control group, for instance: Participants opted into a program offering them free contraception. And the study included contraceptive counseling to participants when they signed up and then throughout the study — which might be worthwhile, but isn’t a realistic experiment.

In fact, a good amount of research indicates that the effect of contraceptives on the rate unintended pregnancy is more dependent on proper use than on cost and access.

Proper use is especially relevant in regard to oral contraceptives, the most commonly used type of contraceptive in the United States. A Guttmacher Institute study found that inconsistent or improper use caused 76 percent of unintended pregnancies among oral contraceptive (i.e., the pill) users. The majority of women who do not use contraceptives consistently cite ambivalence about becoming pregnant as the reason, while ethnicity, educational attainment, level of sexual activity, and relationship status were also significant factors. While one study suggests that copay-free contraception can increase use of methods more reliable than oral contraception, the fact that ambivalence about pregnancy is such a concern for many women suggests there are limits to how much that might help.

Socioeconomic status may have little impact on consistency of use. Women with private insurance and those using publicly funded clinics experienced the same rate of gaps and inconsistencies in contraceptive use, further indicating that inconsistent use may not be directly tied to costs. A 2011 University of Michigan study found that while price increases did reduce oral contraceptive use, particularly among financially constrained women, the rate of unintended pregnancy was not significantly changed. The study reported that women had fewer sexual partners and effectively used other forms of contraceptives to avoid pregnancy.

Moreover, the mandate will only address these financial barriers, while doing little about access. There’s an important distinction between the two: While the cost of contraception can sometimes be a barrier, it is not the cost of oral contraceptives themselves that is prohibitive; rather, it is often the cost of the doctor visit associated with accessing oral contraceptives that poses a problem. Additionally, the inconvenience or impossibility of setting aside the time for and getting to a doctor’s visit limits access for some women. That’s in part why the American College of Obstetricians and Gynecologists recommends making oral contraceptives available over-the-counter to improve access, an idea that’s gained fans on both the right and left.

Some of the problems with the effectiveness of oral contraceptives can be eliminated by long-acting reversible contraceptive (LARC) methods such as IUDs and dermal implants. LARC methods are more effective because they require no consistent user action to work and remain effective for several years. In the past, the relatively high upfront cost of implanting IUDs and dermal devices and doctor’s liability concerns have limited the use of these methods. The Affordable Care Act requires that health insurance plans cover IUDs and dermal implants, so cost is no longer a barrier to LARC methods. But doctors may remain reluctant to perform implants due liability concerns, making free contraception less effective at reducing unintended-pregnancy rates, and the methods simply remain unappealing to many women.

With oral contraceptives and other user-dependent methods, user consistency appears to be the primary barrier to reducing unintended pregnancy. And regardless of their affordability under the new health-care law, access to LARCs remains limited because of doctors’ liability concerns. Offering copay-free contraceptives will not address either of these issues.

Instead, perhaps public-health efforts to raise awareness about the importance of consistent contraceptive use, making contraceptives available over the counter, or restructuring malpractice laws to reduce liability concerns about LARCs would better meet the compelling public interest of reducing the rate of unintended pregnancy. Regardless of what approach, or combination of approaches, may be effective, it’s clear that simply providing free access to contraceptives is a merely a popular policy that fails to address key factors causing high rates of unintended pregnancy.

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