Marilyn Keefe is Vice President for Public Policy at the National Family Planning and Reproductive Health Association (NFPRHA).

The promise of dramatically lessening—and someday, eliminating cervical cancer completely is a goal we can all get behind. Right? Well, maybe in the long run but not too quickly—and not this week. What should be a slam dunk on the public health front has, at least temporarily, gotten sidetracked because of an overly aggressive marketing campaign by Merck which has fueled charges by right wing groups like the Family Research Council that parental rights are being violated and that giving adolescent girls the HPV vaccine will somehow lead them away from abstinence and down the path of sexual depravity. Assuming, of course, that we accept the dubious proposition that HPV—that little known virus—plays a significant role in a teenager's decision to engage in or abstain from sexual activity. Research shows it does not.

From a practical standpoint, some of the biggest issues surrounding the HPV vaccine are getting lost in controversy, including an inadequate vaccine delivery infrastructure, the high cost, and a continued lack of understanding among much of the public about the connection between HPV and cervical cancer.

The cost issues are paramount. Merck did reach an agreement with the Centers for Disease Control (CDC) to provide the vaccine to the woefully underfunded Vaccines for Children program (VFC),a federal program that covers the cost of vaccines for uninsured and Medicaid-eligible children under the age of 19, at a reduced price. But that cost—$288 through the VFC—threatens to break the bank of many health care systems and providers. The company also has established a patient assistance program to cover vaccine for some lower income women in the 19-26 year old group. But the costs and administrative hoops for providers make it a cumbersome and still expensive option at best. Providers attempting to access the patient assistance program are required to pay the up front cost for the first dose of the vaccine ($120)—a significant barrier—although replacement doses are free. Furthermore, the program is unavailable to many government-funded providers—even if they don't get government funds for the purpose of providing the vaccine. This means that many of the already sexually active women who see the ubiquitous "One Less" commercials and arrive at publicly funded family planning clinics hoping to avail themselves of this breakthrough vaccine won't have access.

The situation in the private sector is still problematic as well. While many insurance companies are paying for the vaccine, coverage is far from complete. Doctors are expected to pay the high up front cost on the hope of later reimbursement, which may or may not cover the cost of the vaccine, the storage, and its administration, making many unwilling to even stock the product. This problem was driven home by the experience of an employee of NFPRHA who began her odyssey by calling the insurance company to confirm that the vaccine was covered. The "yes" from our insurer was just the beginning of her saga. She next called her doctor's office for the appointment and was told her doctor didn't stock the vaccine. Strike one. She then called a second gynecologist and was told that this doctor, too, didn't stock the vaccine, but that the doctor could give her a prescription for the vaccine that could then be administered by the doctor. However, this created a Catch-22, for beyond the obvious issues with trying to get a vaccine from a pharmacy, she had a bigger problem—even if she could get it from the pharmacy, her insurance would not cover the pharmacy-to-patient-to-doctor-back-to-patient route; it had to go directly from doctor to patient, with no middle man in between. Strike 2. Tired of blindly calling doctor's offices to see whether they had the vaccine, our intrepid staffer then contacted the local health department. Surely they could tell her where she could go to get the vaccine? Strike 3. They had no idea. Finally, after another round of phone calls and searching on the internet, she was able to get the first dose of the vaccine—at the local Planned Parenthood, which her insurance company said it would cover. She got her first dose of the vaccine... followed by a statement from the insurance company saying they would not reimburse most of the cost because the vaccine was not administered by a doctor. And the battle continues...

Many women will not be as "lucky" or as persistent as our staffer was. There are nearly 17 million uninsured women in the United States, a number that grows daily. Many women—especially in the 19-26 year old aged group, don't have any type of insurance—public or private. At $360 for the vaccine, it is certain to be out of reach, even if they can even find a health care provider who offers it. Title X, the nation's family planning program, provides high-quality reproductive health care to nearly 5 million women each year, the majority of whom are low-income and disproportionately women of color, populations that are most at risk of developing cervical cancer. Title X-funded family planning clinics, which provide 2.6 million Pap tests each year and often provide low-income and uninsured women with their only source of health care, represent the best hope for girls and women ages 13-26 to receive the vaccine. Yet most of these clinics, which have been starved of federal funds for years, don't have the resources to offer the vaccine to their patients.

An estimated 80 percent of women will have contracted HPV by age 50. It is therefore critical that all eligible women have access to the vaccine. If some of the money spent to lobby legislatures to endorse mandatory vaccination for adolescents was spent on services to the women most in need, and to better educate the public about the benefits of the vaccine and its relationship to cervical cancer, we would all be better off.

Marilyn Keefe is Interim President and CEO for the National Family Planning and Reproductive Health Association (NFPRHA).

The signs are everywhere: wreaths and lights decorate lampposts and buildings, shoppers scurry to and fro in search of gifts, the "do nothing" Congress is finally over... yes, the holidays are here and not a moment too soon. I don't think it is an overstatement to say that this was another difficult year. Once again, reproductive rights were under attack in America, from Supreme Court nominations to parental notification, from funding for the Title X family planning program to the hopefully overstated war on contraception.

Lest I seem too "Bah, humbug," however, I should point out some of the bright spots of 2006. Plan B was finally approved for over-the-counter sales, the South Dakota abortion ban was defeated, the first-ever HPV vaccine hit the market, and a handful of states turned down federal abstinence-only-until-marriage program dollars in recognition of the dangers inherent in these programs. Come this January, Democrats will have control of Congress, which we can only hope will finally bring an end to the kinds of anti-family planning, anti-choice legislative attacks that have been the centerpiece of social conservatives' agenda for the last twelve years.

Still, while the prospects of a new Congress sometimes make me as giddy as a five year-old on Christmas morning, I am left with a nagging feeling of dread at the thought of what may lie in store for 2007. Opponents of contraception - especially in the Bush Administration - remain as dedicated as ever to their cause. Yet, ‘tis the season, a time of hope and optimism and a chance to focus on new beginnings. With that holiday spirit in mind, allow me to share a few items from our wish list for reproductive rights for the new year. As John Lennon said, "Let's hope it's a good one..."

Wish 1 - The 110th Congress Goes Down in History as the "Do Something Great" Congress: Let's put all the polarizing rhetoric and playing-to-the-base behind us. There are a number of pieces of legislation out there on which all sides can come together. The Prevention First Act comes to mind. The idea behind this legislative package is simple: increasing access to contraceptive services improves women's health and reduces the need for abortion. Contraceptive use has vastly improved maternal and infant health and has been the driving force in reducing national rates of unintended pregnancies, STDs, and abortions. Prevention First capitalizes on this concept by authorizing an increase in funding for Title X (the nation's family planning program); expanding Medicaid family planning services to women with incomes up to 200 percent of the federal poverty level; and requiring private health plans to cover FDA-approved prescription contraceptives and related medical services. The bill also addresses access to emergency contraception, and in the next session should also shine a spotlight on the education side of the equation by including a provision supporting comprehensive sex ed. Prevention First isn't the only way Congress can improve women's health, but it would be a great start.

Wish 2 - Politics No Longer Trumps Science: One of the hallmarks of the Bush Administration, unfortunately, has been the advancement of political ideology over scientific fact. FDA's nearly three-year delay in approving Plan B emergency contraception is perhaps the most obvious, but not the only, example. The federal government's continued promotion of abstinence-only-until-marriage education programs - despite no solid evidence that these programs work - is yet another example. But the most recent example is the appointment of Dr. Eric Keroack as the new Deputy Assistant Secretary for Population Affairs (DASPA). In a nutshell, the DASPA runs Title X, a program committed to ensuring access to contraception and reproductive health services for low-income women. Dr. Keroack has demonstrated a sincere commitment to opposing abortion and supporting abstinence, but his public statements, writings, and professional associations leave family planning a question mark at best. In fact, the website for "A Women's Concern," the group of crisis pregnancy centers at which Dr. Keroack was Medical Director, states that the centers will not distribute, encourage the use of, or offer referrals for contraceptive drugs and devices, even calling the use of birth control degrading to women. The real point is how does someone with a questionable stance on access to birth control manage to find himself heading the nation's family planning program? How does that happen, if not for the desire to put ideology ahead of reason, politics ahead of science? In the new year, I can only hope that reason will finally emerge from the wilderness to which it has seemingly been banished.

Wish 3 - Everyone Finally Understands Why Contraception is a Critical Component of Women's Health: The benefits of family planning and access to contraception are proven. Women are more empowered to choose when to have children and how many to have. With control over this decision, women can take control over their education, finances, and health. In fact, the Centers for Disease Control and Prevention included family planning in their published list of the "Ten Great Public Health Achievements in the 20th Century." Nearly 90 percent of Americans support access to contraception. Ninety-eight percent of American women have used some form of contraception during their reproductive lives. Title X has been providing contraception, as well as fundamental health care like breast exams and cervical cancer screening, to low-income women for more than 35 years. This was a non-controversial program when it was introduced - then-Congressman George H. W. Bush (yes, George senior) was one of the bills chief advocates - and should not be controversial now. Yet somehow the far right has conflated contraception with the moral degradation of society, blaming it for everything from harming relationships between men and women to actually causing abortion. If I had just one wish, it would be that those who oppose contraception would finally wake up and smell the eggnog. Contraception is not the enemy; ignorance of the need for contraception is. Ensuring access to contraception is a mission we all can, and should, support.

Marilyn Keefe is Vice President of Public Policy for the National Family Planning and Reproductive Health Association

Any amateur magician seeking to master the art of illusion should contact the Food and Drug Administration (FDA) for lessons, as the agency has all but perfected its smoke and mirrors routine. For the past three years, FDA has succeeded in tricking the audience - in this case, the American public - into believing that it is taking real steps toward making Plan B emergency contraception available over-the-counter when in reality the agency has been standing still, a feat that may well rival any David Copperfield performance.

The audience, however, is finally starting to see through FDA's bag of tricks and recognize it for what it is: foot-dragging. On Monday, after a year of inaction, FDA suddenly announced that it is ready to re-engage in talks with Barr Pharmaceuticals on making Plan B available over-the-counter. The decision, FDA said, was the result of a "thoughtful and comprehensive" deliberative process to ensure that "the right policies are in place to promote [Plan B's] safe use." In other words, the last year of total silence from FDA on Plan B was worth it because, round of applause, they used the time to work through their issues and can now move forward.

Unfortunately, we've heard that line before. Those of us who recognize that Plan B, which is simply a concentrated dose of birth control pills, is a critical component of basic health care for women and is an important addition to the contraceptive options available to all women, have been ready to "move forward" since 2003, when a joint FDA advisory panel voted 23-4 in favor of approving Barr's application to make Plan B available over-the-counter for all women. FDA staff concurred with the advisory panel, but the acting director at the time issued a "not approvable" letter, claiming that more data was needed and suggesting to Barr that an age restriction might fix the problem and help move the process ahead.

Barr did as it was asked and amended its petition, requesting that FDA make Plan B over-the-counter only for women 16 and older, and keeping it prescription-only for women 15 and younger. That was in 2004. By 2005, FDA had still not issued a decision, so Senators Hillary Rodham Clinton (D-NY) and Patty Murray (D-WA) placed a "hold" on the nomination of Lester Crawford to be FDA Commissioner until the FDA issued a decision on the Plan B application. FDA assured the Senators that it would issue a decision quickly, so the Senators lifted their hold. Unfortunately, the agency's idea of issuing a decision was to instead issue a notice shortly after Crawford was confirmed asking the public to comment on whether the agency in fact had the authority to approve the two-tiered application it had solicited.

Since those comments were due to FDA nearly one year ago, the agency has not said one word about "moving forward," leaving all of us to wonder whether FDA would ever deal with Plan B again. Then Monday, out of thin air, FDA said that after spending the last year thoughtfully deliberating it was ready to talk. Really? Monday's announcement couldn't possibly have had anything to do with the confirmation hearing for Acting FDA Commissioner Andrew von Eschenbach, scheduled for Tuesday? Of course not, just like all the delays over the last three years had nothing to do with putting political ideology ahead of scientific facts.

Despite the abundant scientific evidence that Plan B is safe for all ages and could prevent as many as half of the three million unintended pregnancies in the U.S. each year, the current administration and right wing extremists don't want women to have access to emergency contraception, period. They have decided - wrongly - that access to Plan B will encourage promiscuity among women, but they couch these views in concerns over whether the drug is safe for adolescents, despite evidence to the contrary. Last year FDA reported that scientific data shows that Plan B is safe for 17-year-olds. Monday, FDA's announcement suddenly changed the approval age it would discuss with Barr to 18, a shift clearly based on little more than the administration's preference that adolescents not have access to the drug.

Senator Clinton was right to say that FDA is "slow-walking" this process. The delays over the last three years have not been caused by real concerns over public health, as FDA is charged with addressing, but by politics run amok. This latest attempt to manipulate the Senate and the American people into believing that FDA is moving closer to making a non-political, science-based decision on Plan B simply isn't going to work. The audience has seen through the smoke and mirrors, and just isn't buying it anymore. It's time for the show to close and for FDA to make a final decision on Plan B. In the words of Senator Murray, "Fool me once. We're not going to go there again."

The problem? The inability of small businesses to afford health insurance. Congress’s solution? Allow insurance companies to discriminate against employees based on everything from how old they are to where they live and take away state protections that guarantee coverage of basic health care services. Makes a lot of sense, doesn’t it?

Here’s the deal: the guiding principle of this complex legislation seems to be that it is better for most people to get next to nothing than for many people to get insurance that is actually worth something. In exchange for making insurance available to more people, the bill exempts many health insurance plans from critical state mandates, including guarantees of benefits that states deem critical, such as coverage for cancer screenings and treatment, diabetes supplies, mental health, preventive care, rehabilitation, well-child care and immunizations, maternity care, and contraception. Twenty-four states currently have laws requiring that insurance companies cover birth control if they cover other prescription drugs. Passage of this bill could stop that progress in its tracks.

Along with offering sub-standard insurance plans of no real benefit, HIMMA would also make it much more expensive for currently insured groups to retain affordable comprehensive coverage. The bill would allow insurance companies to sidestep state consumer protections against discrimination, allowing the industry to set higher rates for women, the elderly, those who are or have been sick, or even people who live in rural areas. The inevitable result, of course, is that companies with older or sicker workers will face much higher premiums that will either have to be passed onto the worker or will simply make insurance unaffordable altogether. It is not hard to imagine a day where questions like “Have you ever had cancer?” or “Do you live within 15 miles of a hospital?” become a routine part of job interviews in an effort to keep insurance costs down. It is equally easy to imagine a day where small businesses simply won’t hire any worker over the age of 50, all in the name of maintaining the meager insurance the company is able to offer its employees.

Congress is trading quality for quantity, the result being a net loss for all of us. Who is the real beneficiary of this arrangement, you ask? You guessed it: the insurance industry, who will be able to charge higher premiums to more people for substantially less service than it provides now.

Which leaves us to ask, why is Congress offering us so much less than it demands for itself? The cynic would say it is because they don’t care, since they will never have to live under the policy they’re selling. Yet maybe it is simply that Congress just doesn’t get it. Maybe Congress doesn’t get that calling someone “insured” is not the same as giving someone insurance. Maybe Congress doesn’t get that if this bill passes, all we will have are “bare bones” insurance plans that are little better than two aspirin and a band-aid, wholly inadequate to cover most of the ailments which you need insurance for in the first place. Maybe Congress doesn’t get that S. 1955 is nothing but an empty promise and an illusion of security at a time when real, workable solutions are needed to address the nation’s health care crisis.