Why Your Insurance Doesn&x27t Want to Cover Your Birth Control | Time

When the Affordable Care Act was passed a decade ago, many women rejoiced: The law required most insurers to cover birth control in full, with no out-of-pocket costs. But a decade later, the promise of free contraception remains out of reach for many.

The reason is buried in the fine print. The law requires insurers to cover, without copay, at least one form of each of the 18 Food and Drug Administration-approved birth control methods, such as pills, intrauterine devices (IUDs), patches, and rings. if patients have a medical reason for needing a contraceptive that is not fully covered by their plan, insurers must provide a “timely exception process” that allows the patient to obtain that covered contraceptive. In theory, almost anyone with private insurance should be able to easily access whatever type of birth control they and their provider decide is best for them. But in reality, insurers have refused to fully cover many newer contraceptives, arguing that they already cover an older version in the same category. patients who want or need those uncovered contraceptives are diverted, advocates say, into lengthy and cumbersome prior authorization processes and are often denied coverage or assessed unexpected costs.

Reading: Why birth control should not be covered by health insurance

At the heart of the problem is a clash between two extraordinarily powerful industry forces, Big Pharma and Big Insurers, who collectively spent tens of millions of dollars last year lobbying the federal government on this and many other problems. drugmakers argue that insurers, by refusing to cover newer products, are discouraging innovation. Insurers, for their part, say they offer enough varieties of contraceptives to fully comply with the ACA—and that without coverage limits or federal action to control drug prices, insurance plans would become unaffordable. meanwhile, patient advocates say ordinary Americans are caught in the middle, unable to access the free contraception the law is supposed to guarantee.

Congressional Democrats have taken sides. They are pushing the Biden administration to issue more specific guidance on the exceptions process and level penalties against insurers who fail to comply, especially with regards to reproductive health care in the US. uu. It could change soon if the Supreme Court strikes down the nation’s right to abortion this spring.

“People who can’t get the birth control they need are likely to go without it or use a method that doesn’t meet their needs,” says Mara Gandal-Powers, Director of Access to Birth Control and Senior reproductive health and rights counselor at the national center for women’s rights. “And that is not the objective of this part of the law. the point is… to help people prevent pregnancy when they don’t want to get pregnant.”

patients struggle to access contraception

Last fall, a group of Democratic House Committee Chairmen and then Senators Patty Murray and Ron Wyden sent letters to the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury. In January, the three agencies responded with FAQs reminding insurers of the ACA rules and warning them that the agencies were “actively investigating” the complaints and could take further enforcement action. then in February, a group of 34 Democratic senators sent another letter urging agencies to develop guidelines for a clear contraceptive exemption process. Last month, another group of more than 100 House Democrats sent another letter, urging more enforcement action and asking agencies to help raise public awareness of ACA’s requirement.

Patient advocates say while they applaud agencies’ prolific letter writing and FAQs, it’s not enough: It’s clear women across the country are still being charged for birth control , or are denied contraception altogether. The National Women’s Law Center has a hotline where people can get help appealing coverage denials, and it’s still taking reports, says Gandal-Powers.

In many cases, patients prefer one type of birth control over another because it has fewer side effects, is safer or more effective, advocates say. about 45% of pregnancies in the us uu. they are unintentional, and providers say contraceptives are more likely to be successful in preventing pregnancy if people can take them correctly and tolerate side effects. “It is very important to find the contraceptive method that meets your needs. otherwise, they won’t take it,” says beth battaglino, a maternal-fetal medicine nurse practitioner and executive director of the healthywomen patient advocacy group.

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It is not clear how widespread the problem is, although millions of women may be affected. A report by the nonpartisan Kaiser Family Foundation last year found that 21% of women with private insurance still paid some out-of-pocket costs for contraception, and researchers say violations can have a significant impact on patients. . Reports compiled by the National Women’s Law Center show that in some cases, patients who could only use a specific type of birth control for medical reasons found their plan didn’t cover it at no cost and didn’t offer a clear exception process, leaving patients to pay hundreds or thousands of dollars out of pocket. other complaints said that women were charged thousands of dollars for the services necessary to administer their contraception.

Additional patient reports shared separately with time showed that pharmacy benefit managers require patients to complete what’s called step therapy, a process in which a patient must try and fail with other medications before a insurance covers the requested medication. a time-reviewed cvs caremark letter told a patient that she must try and fail with three other types of contraception before obtaining coverage for her preferred contraceptive. at least five other contraceptive agents.

Advocates point out that this is not only time consuming and unpleasant for patients, but the risks of an unwanted pregnancy are now greater for many women across the country. The supreme court is expected to rewrite abortion rights in one case this term, and already conservative states have restricted abortion access ahead of the court’s decision.

murray, chairwoman of the senate committee on health, education, labor and pensions, says she has been “very vigilant” as states have tried to restrict access to reproductive health care. “It’s scary that in 2022, women in this country have to say, ‘Will I be able to get the birth control I need? Will I be able to decide when, where and how I am going to have a family?’” Murray says at the time. She added that insurers should have been complying with the ACA “from day one,” and she hopes federal agencies will take more action soon. “I really think that since we’re seeing such egregious behavior, they need to take the next step, put out a comprehensive guide, and then have a strong enforcement. that’s the only way insurers will comply with this law.”

hhs and dol told time that they are still actively investigating the complaints. Centers for Medicare and Medicaid Services (CMS) could take six to 12 months, according to an agency spokesperson. “cms takes complaints about contraceptive coverage very seriously and is committed to strict enforcement to ensure insurers and plans comply with the law,” the spokesperson said.

Does limiting coverage harm innovation?

As federal investigations into insurance decisions continue, advocates and pharmaceutical companies say the future of new contraceptive products could be at stake. “I am concerned that if we don’t see these new products gain coverage that it will affect the way companies think about contraceptive technologies and development over the next decade or 15 years,” says Gandal-Powers.

Some research has shown that when insurance coverage for drugs or vaccines is expanded, it can lead to more investment in new products. An nber working paper published in 2020 offered a similar conclusion: When pharmacy benefit managers, who monitor prescription drug coverage for insurers, began excluding newly approved drugs from coverage around 2012, there was a decline. relative investment in new drugs in the classes that were most at risk of being excluded.

Such behavior makes economic sense, says Leila Agha, an assistant professor of economics at Dartmouth College and the paper’s lead author. “The amount of investment in research and development of new drugs seems to depend on how profitable those drugs are expected to be. and the profitability of the new drug will in turn depend on how many consumers can be expected to buy it at what price,” she says. “So if you make a drug more expensive by moving it to a less favorable or less generous tier of your prescription drug plan, or by excluding it from your prescription drug coverage altogether, it is reasonable to expect that drug to cost lower. sales, and an expectation of that could affect innovation.”

Insurers’ decision to exclude certain contraceptives puts those manufacturers in a tough spot. Agile Therapeutics, which makes Twirla, a new low-dose contraceptive patch, acknowledged financial difficulties on its fourth-quarter and full-year 2021 earnings call last month. Chairman and CEO Al Altomari told investors that the Biden administration’s FAQ in January was a good sign and that if insurers change how they comply with ACA rules, that could help get more through. twirl recipes. evofem biosciences, which makes phexxi, a new non-hormonal contraceptive gel, had a similar message in its call. “I don’t want to sound delusional and say, ‘Oh, we don’t think that’s a big deal.’ But our sales team leadership was in our corporate office this week, and we had a very serious meeting with Jesus about how hard it is. this,” CEO Saundra Pelletier said during her call in March. She added that while they expect the situation to improve in the coming year, the company’s pharmaceutical representatives have offered to help providers fill out drug prior authorization forms. insurers so they can get through the lengthy exception process if they want to prescribe phexxi.

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Drug manufacturers have also launched lobbying efforts. evofem spent $240,000 lobbying on “federal health policies related to contraceptive service coverage” and “contraception access” last year, while agile spent $120,000 on the issue and therapeutics, which makes annovera a newer vaginal ring, spent $80,000.

insurers try to control health costs

For their part, health insurers say they’re following the law and doing nothing wrong by limiting which contraceptives are covered at no cost. “The plans cover at least one option with no cost-sharing, and often much more, in each of the 18 FDA-designated categories,” said Kristine Grow, a spokeswoman for America’s Health Insurance Plans (Ahip). acronym in English). “Coverage with some cost sharing is not the same as not covered – your coverage is still saving you money.” grow added that it can take time to cover new contraceptives because formularies are typically developed several months before each benefit year.

james chambers, a researcher at the center for health value and risk assessment at tufts medical center, says insurers have no choice but to limit the drugs that are covered. if they don’t, the costs would be unmanageable and those costs would be passed on to consumers. “Health plans have to behave this way to some extent, because if it were just a free market, the health system would just explode in terms of the cost of these therapies,” she says.

The United States spends more on health care than any other wealthy nation, and efforts to reform prescription drug prices have so far stalled in Congress. Chambers, who has studied the variation in how insurers cover specialty drugs, says that ideally, insurers would always make their decisions about what to cover in ways that are evidence-based and put patients first. but of course, reality is complicated.

It is difficult to determine the real impact of reducing pharmaceutical innovation, say the researchers. and even cost arguments can be complex. rep. Jackie Speier, co-chair of the Democratic Women’s Caucus, tells Time that “contraception saves insurers money.” “When you have birth control, you don’t accidentally get pregnant and you don’t have the costs associated with prenatal care and maternity care,” Ella Speier says. “so it’s in their best interest to make sure women have access to contraception.”

But insurance companies often focus on more immediate costs, says Steve Lieberman, a health care policy expert at the USC-Brookings Schaeffer Initiative for Health Policy. Insurers have no guarantee that a patient will stay with the same plan for years, so there is little incentive for them to consider long-term savings or drug innovation that could help reduce costs in the future. “The interest of health plans is to reduce costs as much as possible for medically necessary drugs. And they’re not concerned about whether those rebates are enough to incentivize investors to develop the next generation of drugs,” he says.

lieberman also points out that if a particular drug is truly innovative and different enough from other products on the market, manufacturers can command high prices and insurers will generally cover it. “Pharmaceutical companies have better weapons than health insurers,” she says.

yet as these forces act, advocates and lawmakers say patients are caught needing access to their birth control.

“You’re not going to control costs at the expense of women,” says Speier. “You are going to comply with the law. does not have the option to require a copay for women accessing contraception. so fix it or we’ll come back with a sledgehammer if need be. hopefully, that won’t be necessary.”

write to abigail abrams at [email protected]

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