Physicians' Stories: Insurance Coverage for Contraception Changes Women's Lives

My patient Michelle, age 25 and newly married, has a severe congenital heart disease. Pregnancy would be life-threatening; Michelle has a 50% chance of dying if she carries a baby to term. She isn't willing to take that risk.

Condoms are effective only 85% of the time, and the pill isn't safe with her heart condition. Together we agreed that the IUD would be best, an extremely safe and effective method that costs $800. Michelle was able to afford it only because her job's insurance paid for it in full.

If she worked for one of the institutions now in court over contraception coverage, Michelle would be suffering financially or gambling with her life—all in the name of someone else's religious freedom.—Sara Pentlicky, MD, Philadelphia

Raquel, age 23 and mother to a seven-year-old son, had never been able to afford long-acting, effective contraception. In her subsequent unintended pregnancy, she was hospitalized with pulmonary hypertension, or high blood pressure in the lungs, a life-threatening condition in pregnancy. After four months in the hospital, Raquel gave birth to a girl. Twenty-four hours later, she died, her son crying by her side. She left behind two kids and a compelling message about the need for contraceptive coverage. Lack of coverage can have tragic consequences. I will never forget Raquel and her family. —Jennifer Kerns, MD, San Francisco

Sandy worked at a Catholic hospital in Baltimore. She came to me seeking help for her heavy, long periods. Oral contraceptives would have altered her quality of life dramatically, but because her insurance would not cover birth control, she couldn't fill the prescription. Sandy’s health insurance should have covered all of her health care needs. —Zowie Barnes, MD, Baltimore

As an obstetrician/gynecologist, I have many patients like Jennifer, a 22-year-old Catholic mother of one. She has decided to postpone expanding her family while she works and finishes school. For birth control, she selected an IUD, a long-acting, extremely effective method. Her job’s insurance took care of the cost.

But if Jennifer worked for an institution that refused to cover contraception, she might not be able to afford the device or strain her family finances to afford it. Or she would be forced to set aside the IUD she knows would be best for her and use cheaper, less effective birth control, increasing her risk of an unintended pregnancy. With health reform’s contraceptive coverage, more women will finally have access to affordable contraception.—Kathleen Morrell, MD, Brooklyn

My patient Cathy, now in her 30s, was a teen mother. Recently she brought her two daughters, both in their teens, to see me for contraception. The young women each received an IUD, a highly effective contraceptive that the family wouldn’t have been able to afford out of pocket. Cathy offered her daughters an opportunity she didn’t have: a chance to finish school and decide when and if to become parents. She gave them the gift of self-determination.

As we celebrate such signs of progress, we must remember that many women still lack access to affordable birth control options—for themselves and their daughters. All women should be able to count on their health insurance for this basic need, no matter who employs them.—Lori Gawron, MD, MPH, Chicago

In these hard economic times, I have patients who must choose between contraceptives and household bills, settling for cheaper, less effective forms of birth control. Consider Michelle, 22, whose migraines would get worse with the estrogen in most birth control pills. She and I decided on an intrauterine device, with its extremely low failure rate compared to the pill and most other contraceptives. But Michelle’s insurance doesn’t cover the IUD, and she couldn’t afford its $750 cost. I prescribed progestin-only birth control pills, both of us knowing her insurance had put her at greater risk of unintended pregnancy.

This is shameful. Birth control is a fundamental part of women’s health. Every employer, regardless of religion, should provide an insurance plan that meets this need.—Zowie Barnes, MD, Baltimore

Mary is a 28-year-old mother of two. She works as a medical assistant at a religiously-affiliated hospital. She had multiple complications with her most recent pregnancy and was told that she should never become pregnant again. For Mary, another pregnancy could be life-threatening. Mary loves her two children and wants to make sure she stays healthy for them. She and her obstetrician decided that an IUD would be the best way to prevent a future pregnancy.

At her doctor’s office, she found out that her insurance, because it is through her work, does not cover contraception. She was surprised and confused that, despite her doctor’s recommendation of an IUD, her insurance would not cover it. I met Mary when she came to our Title X clinic. We were able to provide her with an IUD through a family planning grant. It was unfair to Mary that her insurance did not adequately protect her health and that she did not know in advance about the gaps in her coverage. I hope that in the future women like Mary can rely on their insurance plans for the resources to stay healthy and be there for their families.—Tara Kumaraswami, MD, Chicago

Maria is 15 years old. I met her after she had her first menstrual period. She bled so heavily that she had to be admitted to the hospital and receive a blood transfusion. The best treatment for Maria’s condition (menorrhagia) is birth control pills. They regulate the menstrual cycle and prevent dangerous bleeding for patients like Maria. In fact, one-third of U.S. teens use contraception for reasons other than avoiding pregnancy. Maria and her family are practicing Catholics. I discussed birth control pills with her parents. If she did not start the medication, every time she had her period she would be at risk of bleeding so much she would need another transfusion—possibly every month. After carefully weighing the decision, her parents decided that birth control pills would be the best way to keep Maria healthy and out of the hospital.

Birth control pills are not just for contraception—they help manage conditions like Maria’s as well as lower the risk for certain cancers. All families need affordable access to medications that safeguard their health, including birth control.—Yolanda Evans, MD, MPH, Seattle

When I was in residency in Pennsylvania, I took care of Rita, a young Catholic mother of five. Rita was suffering from a serious heart defect. She was six weeks pregnant and had a defective cardiac valve that had to be replaced with a synthetic one. Pregnancy put her at high risk for blood clots forming on the new valve and travelling to her brain, where it could kill her.

Rita had not been using contraception because she had no insurance to make it affordable—not because she didn’t want to use it. While in the hospital, despite taking blood thinners to treat her clots, Rita had a stroke. The woman I had spent hours with talking about caring for her five living children, her marriage, how to handle her unplanned pregnancy—that woman could now no longer speak or walk. When I think of birth control access, I think of Rita and her family.—Jennefer Russo, MD, Orange, CA

I grew up following the Catholic mission of education, stewardship, and giving to those less fortunate. I entered medical school to continue serving others. But there, I discovered the limits of Catholic charity.

In an emergency room, I watched a mother scream as her 16-year-old daughter died in her arms. The girl had intentionally overdosed on Tylenol. She saw no other solution for her unintended pregnancy. Birth control could have saved her life.

Although Catholic teachings forbid contraception, I resolved to provide my patients with the full spectrum of reproductive health care—supporting women who want to become parents as well as those who aren't ready. Birth control saves lives and keeps women and families healthy, tenets I see as central to the Catholic mission.—Lori Gawron, MD, MPH, Chicago

Susan worked in administration at a Catholic Archdiocese and her employer provided health insurance that did not cover contraception because of the employer’s belief that birth control is immoral. Susan was in a relationship and did not want to become pregnant. Her partner refused to use condoms and the burden to prevent pregnancy fell on her.

Because of her high blood pressure, Susan could not take birth control pills, and she and her doctor decided that an IUD was her best preventive health care option. But Susan could not afford the hundreds of dollars for the device and insertion. She went without any birth control, became pregnant and then had an abortion that should have never become necessary.—Anonymous U.S. physician

Two years ago, my colleagues and I treated Beth, a 40-year-old with complications from catastrophic blood loss during her period. We couldn’t save her. The right contraception could have prevented her death.

The new federal regulation on birth control coverage will go a long way to help women stay healthy and safe. I hope someday it will apply to everyone, no exceptions.—Claire Bolander, MD, Baltimore

Yesterday I took care of Adrienne, a 36-year-old mother of three who wanted to use an intrauterine device (IUD). However, she doesn’t have medical insurance, or the approximately $800 it would cost her to pay for an IUD. While it’s true that some contraceptives are relatively cheap (a condom costs approximately $1), they are also less effective. The one year failure rate for a condom is 15%, compared to less than 1% with an IUD.

Covering all contraception for all women will expand access to long-acting, highly effective birth control methods and will allow women to make decisions that are right for them.—Aileen Gariepy, MD, New Haven

My patient Maria is a 20-year-old with epilepsy. Her seizures clustered around the time of her period and had become so debilitating that she had to repeat her freshman year of college. I recommended a hormonal contraceptive injection to stop her periods and improve her seizure control.

Unfortunately, the student insurance plan provided by her Catholic university did not cover “contraceptives” for any reason. Maria’s parents are paying out-of-pocket for their insured daughter to receive a medically necessary medication.—Lori Gawron, MD, MPH, Chicago

I am an obstetrician/gynecologist, and every day I see patients who rely on their insurance to pay for contraception. There’s Alice, who wouldn’t be able to afford the $1,000 out-of-pocket cost of an intrauterine device (IUD) on her grad student salary—thanks to her insurance coverage, she has an IUD so she can wait to start a family until she finishes her degree. I think of Tanesha, whose debilitating migraines every month often forced her to miss work. The only treatment that reduced her pain? The birth control pill, covered in full by her insurance.

And then there’s Amber, who suffered from severe heart disease during her last pregnancy. An unplanned pregnancy could kill her, leaving her three kids without a mom. Thankfully, her insurance plan covered her contraceptive implant, giving Amber three years of highly effective contraception.

All of my patients and the millions of women across the country deserve access to these safe, reliable, and vital drugs and devices, regardless of where they work. Any decision about whether to use birth control and which method must be left to the woman and her health care provider—not the organization she works for.—Jennifer Robinson, MD, MPH, Baltimore

Just last week, I saw Leslie, who is in her 30s. Leslie has a malignant tumor in her breast, and it is the type that feeds on hormones. If Leslie were to become pregnant, the resulting upsurge in hormones would make her tumor grow faster, rapidly increasing the likelihood that her cancer would spread and kill her.

Leslie can’t use less expensive forms of birth control, like the pill, because they contain hormones. For her, a copper IUD is the only option, but it costs at least $800, way beyond her budget. What employer would be so cruel as to deny Leslie this vital health care at a price she can afford?—Anne Davis, MD, MPH, New York, Consulting Medical Director, Physicians for Reproductive Choice and Health

Four years ago I graduated from medical school. I had paid for school on my own and was deeply in debt. I was excited to begin my residency and start earning a small paycheck. At the beginning of my residency I had an intrauterine device (IUD) placed using my new health insurance from Catholic Healthcare West. I wanted to be sure that I didn’t become pregnant and I knew an IUD was the best option for me. IUDs cost about $1,000 up front to insert. There was absolutely no way I could have afforded the payment without insurance. I shudder to think of women out there who would be left with few options if religious insurance plans were allowed to refuse this coverage.—Andrea Angelucci, DO, Los Angeles

My patient Ava is 45 years old and has four children. Two years ago she suffered a stroke. To prevent future strokes, Ava must take a blood thinner. Her condition is complicated because that medication causes heavy, sometimes life-threatening, bleeding when she has her period. An IUD is the safest option to reduce that bleeding.

But Ava’s husband works as a facilities engineer at a large Catholic hospital, and his insurance will not cover contraception for any reason. The fee for an IUD is over $1000, an outlay that Ava and her family could not afford. I had to refer her to a Title X clinic for assistance. IUDs not only prevent unintended pregnancy, but they also help keep women like Ava healthy. An employer’s refusal to cover this necessary medication creates hardship for families like Ava’s and stretches the safety net meant to cover those without insurance.—Lori Gawron, MD, MPH, Chicago

Some women I treat use contraception because they have medical conditions that could kill them if they became pregnant. I think of Denise, who suffered from cardiomyopathy (a potentially lethal heart disease) during pregnancy. If she were to get pregnant again, she would have a significant risk of heart failure. Denise deserves insurance that covers contraception and her other basic health needs, wherever she works.—Andrea Angelucci, DO, Los Angeles

My patient Rebecca was recently married and wanted to start a family. However, she has a genetic condition that weakens her blood vessels and caused a stroke when she was young. Multiple doctors counseled her that a pregnancy could further damage her blood vessels and kill her. Rebecca and I decided on an intrauterine device (IUD) as a long-lasting, highly effective contraceptive that would protect her against the life-threatening risks of pregnancy.

Because Rebecca's insurance plan included birth control, most of the $913 IUD device and insertion fee was covered. But I have other patients whose health is at risk because their employers refused contraception coverage. These women can't afford such high upfront costs out of pocket. I look forward to the day when every employer understands that women need a full range of preventive health services, including birth control, to have healthy and productive lives.—Jennifer Tang, MD, Chapel Hill, NC

I care for many women who are employees and students at a large, well respected, Catholic college. These women have no objections to birth control—they are either not Catholic, or among the ninety-eight percent of Catholic women who have used birth control. Most have no idea their insurance does not cover birth control pills or any other contraceptive until they begin working or studying there. When they find out, some panic because they cannot afford the full cost. These amounts can be prohibitive for a family on a budget. The college educates and employs thousands of women; they should not be denied affordable birth control as a condition of studying or working there.—Anonymous U.S. physician

I recently saw Tammy, a married mother of two who has a congenital heart disease. For her pregnancy is life-threatening, and estrogen-containing birth control methods, such as pills and the patch, are will make her condition worse. Fortunately, Tammy had insurance coverage through her employer for her copper IUD (a highly effective and very safe intrauterine device). It cost $1,000. Without insurance coverage for contraceptives, Tammy would have been unable to afford this life-saving device.—Sara Pentlicky, MD, Philadelphia

A few months ago, I met Ellen, a 38-year-old wife and mother with a pacemaker. She developed a rapid and life-threatening heartbeat during her last pregnancy, but as an employee of a Catholic institution, she had insurance that did not cover contraception. In our family planning clinic, Ellen was able to get an intrauterine device (IUD), which costs $800-$1,000, at a reduced rate, and now she has one of the safest, most effective forms of contraception available. For her this means protection for her heart, no more dangerous pregnancies, and the ability to continue working and taking care of her family.—Katherine Damm, MD, Detroit

I recently cared for a 24-year-old woman named Somsri. She had come to see me about contraception. Somsri has a genetic blood disorder that caused a dangerous blood clot in her leg. To manage this condition, she needs to be on an anticoagulant cocktail for the rest of her life. Somsri also should not get pregnant because it would be very dangerous for her.

An IUD would be the best form of contraception for Somsri. Unfortunately, her health insurance did not cover the IUD’s cost, and she did not have $1,000 to pay for it out-of-pocket. Somsri left without an IUD. Her only affordable option was condoms, which have a significant failure rate.

Six months later Somsri was pregnant. Because of her condition, her pregnancy was very complicated and she nearly died, ultimately needing a hysterectomy to stop her bleeding.

All women deserve accessible and affordable contraceptive services, no matter where she works or how much money she makes.—Orawee Chinthakanan, MD, Atlanta

Melanie has worked for many years as an emergency room nurse at a Catholic hospital. She wanted a long-acting, reversible contraceptive, specifically an IUD. But the hospital’s health insurance did not cover birth control. Melanie paid for birth control pills out-of-pocket, but she had experienced an unintended pregnancy while on the pill and knew that an IUD would be more effective.

However, Melanie could not afford the nearly $1,000 for the IUD and its insertion. Instead, Melanie obtained an IUD from a nearby study of a new, experimental type of IUD. Her need for an IUD plainly outweighed her worries about using a contraceptive without FDA approval.—Anonymous U.S. physician

Liz is 27 years old and has three children. I cared for her last year when I delivered her youngest child. Ever since then we have been trying to find her an affordable form of birth control. She is on Medicaid and has a managed care plan through a religious carrier. Most Medicaid plans cover birth control, but her policy has an exemption for contraception.

Liz lives with her children in a homeless shelter. She is trying to get on her feet and create a better life for her and her family. Her inability to access affordable contraception puts her at high risk of unintended pregnancy at a time in her life when she is already struggling for survival.—Dana Schonberg, MD, Brooklyn

My patient Julia is in her 20s and poor. Julia loves her two children very much, but their births were medically complicated, and Julia does not want to have another baby. She is content with her family.

Even though Julia is Catholic, she decided that a tubal ligation—or “tying her tubes”—was the best way to prevent an unintended pregnancy. But Julia has Medicaid through a religious carrier, and her plan will not cover a tubal ligation. She had had no idea that her plan could refuse to cover certain services. Now Julia has to go back to using less effective forms of contraceptives that have failed her in the past.—Kathleen Morrell, MD, Brooklyn

Kristen worked as a nursing assistant at a Catholic hospital. Her insurance did not cover contraception. Kristen, who is not Catholic, did not know about this policy until after she started working at the hospital. When Kristen first refilled her prescription for birth control pills, she discovered that she would need to pay $50 per month, a new expense for which she had not budgeted, as her last employer had covered contraceptives.

Kristen was able to afford her prescription for a few months, but could not continue. She later had an unintended pregnancy and needed an abortion.—Anonymous U.S. physician

My patient has an unplanned pregnancy because her insurance doesn’t cover any birth control. She could have afforded to pay for the pill out of pocket, but she takes a seizure medication that makes hormonal birth control less effective. What she needed was an IUD, which would have given her far better protection. The IUD and its insertion cost anywhere from $600 to $1,000. She couldn’t afford it.

My patient’s seizure medication causes birth defects. She was more than a month along when she learned she was pregnant. Her insurance company will pay for the long-term care of a child born with severe health problems but not for birth control.

Now she has decided to have an abortion. Her insurer won’t pay for that, either.—Willie Parker, MD, MPH, MSc, Washington, DC

Christine came to see me for an IUD. She is 40 and had been pregnant recently. She and her husband have two children, and they wanted to have another baby.

But Christine’s insurance doesn’t pay for labor and delivery. Her doctor estimated that even an uncomplicated birth would cost thousands more than she and her husband could afford. And their income was too high for Medicaid.

So instead of having the third child she and her husband wanted, Christine had an abortion, for which she paid in full because her insurance didn’t cover that, either. The final insult? Christine wanted to make sure she wouldn’t become pregnant but her insurance wouldn’t cover her IUD.—Anne Davis, MD, MPH, New York, Consulting Medical Director, Physicians for Reproductive Choice and Health