Unintended Consequences of Health Reform in Massachusetts: New Barriers to Contraception

Clearly the US health care system needs reform.  Massachusetts’ innovative reform legislation in effect since 2007 provides many lessons that federal policymakers should heed as they consider models to reform health care across the nation.

Ibis Reproductive Health and the Massachusetts Department of Public Health Family Planning Program are particularly interested in the impact of health care reform on contraceptive access for low-income women in Massachusetts.  The two organizations embarked on a collaborative research project in late 2008.  Findings from the project highlight the critical need to pay attention to the architecture of reform to protect access to contraception for low-income women.  Focus group discussions with women and interviews with family planning providers reveal new challenges to accessing and providing care under a health care system that includes individual insurance mandates and expands access to private health insurance.

Even with expanded access to health insurance, new barriers to contraception access have developed.  Prescription requirements are confusing and inconvenient for some women who previously accessed their contraception from a family planning clinic.  Providers women like and trust, like family planning or community health centers, may not be covered under private insurance plans, and it is difficult for women to identify what contraceptives are covered and what providers offer covered services. 

Insurance plan information is often confusing and not user-friendly.  The plan websites we reviewed did not allow a search for contraception based on common terms like “the pill” or “the ring” but required the user to know either the brand or generic name of the method. 

Women in Massachusetts rely on their family planning providers to help them understand their insurance, translate plan information and mailings, and complete eligibility paperwork.  Family planning providers described challenges contracting with the plans that took part in the state-subsidized scheme, and also faced administrative burdens with billing and helping their clients understand what is covered under the new plans.

Women’s health advocates, women themselves, and family planning and sexual and reproductive health service providers need to pay close attention to exactly how contraception will be covered and how preventive care in general will be managed in any national reform plan.  In Massachusetts some new barriers were specific to contraception services—like some plans not covering services provided by family planning providers—but others were more about the logistics of the plans and the eligibility requirements.  Confusing formularies and women moving on and off the plans due to erratic employment or life changes like moving or having a baby will affect more than contraceptive services.   

As Congress continues to debate health care reform, we should ask whether family planning providers and community health centers are included as key providers of preventive health care services to ensure women can continue to access health care with the providers they know and trust.  We should also demand that contraception be covered at low cost, and that information about the full range of methods and how they are covered be easily available and understandable.  We should also argue for prescription coverage that provides more than one month of medication at a time—more cycles of hormonal contraception have been show to increase use—as well as consider innovative strategies for covering the cost of non-prescriptive contraception methods like condoms.  Another possibility for policymakers to consider is legislating low copays for contraception in subsidized plans.

Contraception is not only cost-effective but is critical for women to live the lives they want and protect their health and the health of their families.  Providing complete coverage of preventive and women’s health services like contraception should be part of any national health reform package.