Policy at the Clinic: The ACA role in a woman’s health decisions

Written by Dr. Mary Carol Jennings, NPA member, Boston, MA.

From a certain gendered perspective, the identity and social role of the contemporary American woman is determined by motherhood. I mean not that a woman has a “duty to reproduce”, but rather that her access to effective contraception – to the meaningful choice of if and when to take on the role of motherhood – shapes her self-identity as a woman.
Over the last half a year the partisan-termed “War on Women” has sapped up an inordinate amount of airspace in its rehashing of a question I, for one, thought the American public had already settled: does readily accessible birth control represent a step toward the moral degradation of our society?
This debate was a surprising return to an outdated discussion about society’s responsibility to invest in the future by guaranteeing access to contraception. Enter August, 2012, and with it the new Affordable Care Act (ACA) provision (www.healthcare.gov) concerned with providing preventive healthcare for women. Access to contraception is now included in the cost of a monthly insurance premium, without additional copay under all US health plans – with the exception of the “certain religious providers” clause.
Because hearing is believing, I placed a call to my own carrier to ask how much I would have to pay if I wanted to obtain a long-acting reversible contraceptive method, such as an intrauterine device (IUD). A representative confirmed that there is no additional copay, neither for the device nor for my provider’s visit for insertion. (There is, however, a routine co-pay for the recommended 6-week correct position, or “string”, check.)
In the ideal world the incidence of contraceptive access and contraceptive failure would closely predict the incidence of abortion, but today, abortion incidence is disproportionately skewed toward poor women and women of color1, which trend reflects a societal failure. Abortion access is a divisive topic in contemporary times, but it is a procedure with ancient roots which women obtain 2 whether a sector of society approves of it or not: an honest society has a prevention-based plan to deal with it.
The Hyde amendment, which successfully insinuated a politically biased definition of abortion into the realm of medicine and science, restricts public funding for abortion care; the ACA continues this restrictive policy. This legalistic play fails to decrease abortion numbers but rather introduces delays in time to obtain the procedure (eg. a woman needs time to raise money), which even for this common, safe procedure, increases costs and risk.
Today, contraceptive access is, shamefully, also proving to be a divisive topic. But beyond opinion and political slants, affordable, meaningful access is an important element to reducing the number of women faced with the choice of how to handle an unwanted pregnancy.
The ACA is expanding affordable, meaningful contraceptive access. A recent paper published by the Center for American Progress describes the socio-economic impact of ACA-restricted coverage for abortions and abortion related care, as it “marginalizes” abortion care and services by increasing the number of women whose insurance plans do not pay for abortion care. Restricted funding reduces available care, which widens the impact of our growing American class gap, as “women with private health insurance or personal access to funds are allowed to be agents in their health decisions while poor and low-income women are denied that right”. [IBID]
The impact that increased contraceptive access will have on the national abortion rate depends on real-time utilization of effective methods. Utilization, or uptake, in turn depends on the religiosity-based participation of a woman’s insurance provider; her comfort level and acceptance of varying effectiveness levels of each option; the standards of method acceptance in her native culture; and the advice her provider offers her.
From a provider’s perspective, the act of providing contraceptive option counseling now includes sharing information on access and affordability. As of August 2012, providers of women’s healthcare play a more crucial role in realizing the potential of this policy provision to stem a potential increase in abortion rates.


1 Guttmacher Institute, An Overview of Abortion in the United States, 2011.  http://www.guttmacher.org/presentations/abort_slides.pptx slide 8.
2 Sedgh G et al., Legal abortion worldwide: incidence and recent trends, International Family Planning Perspectives, 2007, 33(3):106–116.