Health Policy Perspective Steve Heilig, MPH
Contraception: Just What the Doctors Ordered A Medical Voice in the Political Debate Contraception exploded onto the front pages this February. But it was not about any new medical break-
through, much as there is room for improvement regarding effective contraceptive options. It was a political and religious debate. But what is controversial about contraception at this late date? Who pays for it, as it turns out. As one headline read, “Changes to Contraceptive Coverage Rules Draw Mixed Reaction,” thus winning an understatement award. Almost all women, including Catholics, ignore religious leaders on this issue if said leaders say “don’t”—when they have a choice. And most men support that practice. The most incisive perspectives in this realm seem to come mostly from women—political leaders, doctors, nurses, and just plain folks. Regarding the current debate, many note that Catholic authorities are trying to have it both ways, claiming all the financial privileges of a church but wanting to ignore any strings that might be attached. Others observe that behind this debate lurked abortion politics—even though one proven way to reduce abortions is to make contraception as easily available as possible. Among politicos, the gender split seems pronounced as well. Three female senators wrote to the Wall Street Journal defending the contraceptive mandate. Some female politicians even felt compelled to boycott the male-dominated House hearing on the topic. Kris Long, a nurse writing in the New York Times, said, “As a former employee of a Catholic-run hospital, I find it appalling that the party of ‘individual rights’ would stand up for a religious bias rather than for the nonCatholic employees who are deprived of the right to choose health insurance commensurate with private needs and beliefs. Why should I not be allowed birth control through my insurance because my boss has a problem with it?” Organized medical voices have been notably muted in this debate. But the contraceptive mandate did not spring anew out of the White House. It is an old idea, long supported among health care policy wonks for both clinical and economic reasons and, last summer, given strong endorsement by the Institute of Medicine (IOM) of the National Academy of Sciences. Their report “Clinical Preventive Services for Women: Closing the Gaps” focuses on preventive care for women, including contraception. In medical circles the report was hardly controversial. But sensing that the IOM recommendations might be more controversial in nonscientific arenas, the SFMS delegation to the CMA unanimously adopted the statement that follows in September, with three (female) SFMS physicians as authors (their names omitted here for safety reasons). www.sfms.org
CONTRACEPTION AS A FULLY COVERED HEALTH INSURANCE BENEFIT Whereas, the United States Institute of Medicine in July 2011 strongly recommended that “the full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity” be a fully covered benefit of all health insurance plans; and Whereas, the costs of contraception have long been identified as a barrier to many women’s optimal use of contraception, with negative impacts on their health and in terms of unwanted pregnancies, as well as discriminatory implications; and Whereas, the Federal administration has just mandated that contraception be a covered benefit, but health insurance industry representatives have voiced their opposition to this measure and might try to repeal it; now be it RESOLVED: That the California Medical Association supports the coverage, without co-payments, of all FDA-approved contraception methods and sterilization as a mandated health benefit of all health plans. We suspected there might be some opposition at the CMA’s October meeting, but in the open debate, our draft policy was strengthened to include voluntary sterilization. It is a concise statement, regarding a private medical matter between women and their physicians. The importance of this mandate is highlighted by recent reports showing that religious control of hospitals in some areas is growing, with resultant restrictions on some services. Obviously the SFMS and CMA do not intend to wade into religious conflicts. But the specter of any organizations responsible for medical coverage being able to cherry-pick what they’d pay for—note that some faiths oppose transplants, vaccines, and so on—makes denying coverage of contraception a bad precedent. Ironically, the same week that contraception hit the news, a report was released by the widely respected group Save the Children confirming the tragic fact that one out of four children are malnourished, and many of them are starving to death—at a rate of one every five minutes. Some would say these issues are related. More recently, at least two more states have passed laws favoring disproven “abstinence-only” sex education—again, over the objection of medical groups (and educators, for that matter), and despite predictions that this will increase unwanted pregnancies and abortions in those states. A New York Times columnist labeled all this as “politicians swinging stethoscopes.” Perhaps those opposed to contraception could more usefully direct their resources and energies toward the ongoing tragedies of starvation, unwanted pregnancies, and preventing abortion via proven approaches. To those ends, perhaps they could listen to what doctors know and think. But I won’t hold my breath. April 2012 San Francisco Medicine
31