Bridging the Gap Series : December 2022
Introduction by Vice Chancellor Steve Goldstein
In California, and across the nation, we continue to grapple with a multitude of health insurance issues, many of which undermine the health and well-being of our diverse population. To confront these challenges requires a grounded understanding of the effects of policies and laws and their reform since even minor revisions can impact patients profoundly.
This month in the Bridging the Gap series Dylan H. Roby, PhD, interim chair and associate professor of health, society, and behavior at UC Irvine’s Program in Public Health, considers the impact on women’s health of insurance coverage for contraception, exploring the role of coverage in the disproportionate burden of unwanted pregnancy on women of color.
Roby brings deep expertise built on three decades of experience in health policy research, reform, and insurance markets, including the Affordable Care Act and Covered California. Notably, his work as an investigator using computer modeling in collaboration with UCLA/UC Berkeley’s California Simulation of Insurance Markets (CalSim) has estimated the impact of changing state subsidies, reinstatement of the individual insurance mandate, and expanding eligibility for Medi-Cal coverage. He has also served on the UC-Wide Faculty Task Force of the California Health Benefits Review Program.
In keeping with the UCI Health Affairs commitment to whole-person, data-informed, team-based care, that places the patient at the center and in-control, Roby reminds us that even when we talk about economics, the dollars and cents of health care, the impact is on people. His work is a consummate example of the virtuous cycle of our UC Irvine Health Affairs mission – Discover, Teach, Heal – whereby investigations designed to assess the effects of policies on individuals can be used to improve clinical outcomes and educate the next generation of providers so they understand the many determinants of health and can advocate for their patients, especially the poorly-served.
By Dylan H. Roby, PhD, interim chair and associate professor of health, society, and behavior, UCI Program in Public Health
Under the Affordable Care Act of 2010 (ACA), insurance coverage for contraception was expanded in several ways. Most private health plans are required to cover multiple methods of contraception used by women, including birth control pills, intrauterine devices (IUDs), implants, female sterilization, and related counseling and services. The ACA also required preventive services, including contraception, to be provided without any cost-sharing by patients, such as copayments or deductibles. Having a wide range of contraceptives to choose from helps women avoid unintended pregnancies.
Federal law facilitates access to contraception as a preventive service, however, states are passing laws or engaging in regulation around reproductive health and family planning. While some states have focused on limiting access to abortion services, others have focused on improving access to Long-Acting Reversible Contraception (LARC) and other methods of contraception through increasing funding for family planning services, training programs for providers, and removing barriers in Medicaid reimbursement for LARC insertions and removals.
However, inequities in access and outcomes remain – especially for underrepresented minorities. Women of color face several barriers like fewer community health services with the capacity to deliver all methods of contraception, limited insurance coverage, and even practitioner-level factors such as racial bias and stereotyping.
To best understand where we are today, we need to consider the historical context of the women’s reproductive health movement, which spans more than 60 years of battles, setbacks, and triumphs.
The 1960s saw the start of groups like Our Bodies, Ourselves, and the National Women’s Health Network, which were able to influence policy and enact change against repressive reproductive health policies like sterilization without informed consent. They were able to improve federal regulations to curb the incidence of sterilization abuse, especially among women of color, who at one point were sterilized without informed consent and often following threats of losing public benefits. By the early 1970s, abortion was deemed a fundamental right, protected under the 14th Amendment.
During the 1980s and 90s, women of color began creating more local and national organizations that represent and serve black and brown communities who face disproportionate health issues like experiencing a greater burden of unintended pregnancy in the U.S.
Trying to untangle the complex historical and social context in which women of color experience a greater burden of unintended pregnancy requires a system-based approach. We must start with equitable access to affordable, convenient contraceptives.
A systematic review of research on Long-Acting Reversible Contraception (LARCs), especially among young women has shown it to be safe and highly effective. LARCs are a type of birth control, covered by the ACA, like IUDs, that have shown to be more effective than birth control pills, patch, or vaginal ring. LARCs, once placed by a medical professional, require no user action to be effective after placement. The popularity of LARCs due to their high efficacy in preventing pregnancies has been notable across all races/ethnic backgrounds. In the past 30 years, use among Latinos has increased by 129% and among non-Latino whites, it’s jumped by 128%. Though trends show an increase in LARC use for women of color, public health interventions are still needed to bridge the gap in reproductive health among minority groups.
Furthermore, the evidence shows that improving access to LARCs improves economic outcomes. There are many confounding factors that influence poverty so we cannot ascertain that improving access to LARCs will reduce poverty. However, policymakers and government officials must be reminded that improving access to LARCs can provide all women with effective birth control and ultimately reduces unplanned pregnancies.
With access to certain reproductive health services diminishing in parts of the country, a new framework is needed that addresses this public health challenge from several angles.
Forced sterilization campaigns occurred in our lifetime and although access to contraception is vital, being told to obtain available birth control services in a potentially different setting may feel like pressure tactics or coercion for some women.
Now more than ever, equitable, patient-centered care must be at the forefront of our healthcare enterprise so that we can provide evidence-based approaches for contraceptive education and treatment options to women of all races and backgrounds.
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