PRCH Testimony on Contraception Coverage Rule and Religiously Affiliated Employers

Testimony of Douglas Laube, MD, MEd

Board Chair, Physicians for Reproductive Choice and Health

Submitted to the House Committee on Oversight and Government Reform February 16, 2012

Physicians for Reproductive Choice and Health (PRCH) is a doctor-led national advocacy organization that relies upon evidence-based medicine to promote sound reproductive health policies. PRCH welcomes the opportunity to submit testimony to the House Committee on Oversight and Government Reform for the hearing entitled “Lines Crossed: Separation of Church and State. Has the Obama Administration Trampled on Freedom of Religion and Freedom of Conscience?” Our testimony will show that the new contraceptive coverage policies are medically sound and important for the health and well-being of women and their families.

PRCH supported the recommendation of the Institute of Medicine (IOM) to include contraception in the preventive health benefits for women under the Patient Protection and Affordable Care Act (ACA) and the decision by the Obama Administration to ensure that all women have contraceptive coverage without additional fees no matter where they work. As physicians, we know that access to contraception is essential to the health and well-being of our patients.

About half of all pregnancies in the United States are unintended. Regular use of contraception prevents unintended pregnancy and reduces the need for abortion. Contraception also allows women to determine the timing and spacing of pregnancies, protecting their health and improving the well-being of their children. Contraceptive use saves money by avoiding the costs of unintended pregnancy and by making pregnancies healthier, saving millions in health care expenses. Several contraceptives also have non-contraceptive health benefits, such as decreasing the risk of certain cancers and treating debilitating menstrual problems. Making contraception more affordable is a significant step forward for the health of women and their families.

PRCH appreciates the efforts of the Administration to allow women access to the contraceptive methods that best meet their needs. Contraceptive methods vary and women with their health care providers need to be free to select from the full range of FDA-approved contraceptives. Not all contraceptives are clinically appropriate for every woman. We also know that women and couples are more likely to use contraception successfully when they are given their contraceptive method of choice, be it a birth control pill, a vaginal ring, or an intrauterine device (IUD). The new policy holds the promise of making contraception more affordable and easier to access for millions of women.

I. Women deserve access to contraceptive coverage, no matter where they work or what their income.

Some lawmakers have put forward proposals that would allow any employer to refuse coverage of services to which they are religiously or morally opposed. That is grossly unfair to women, and from a medical perspective would constitute indefensible health policy. All women deserve access to affordable birth control—an important component of preventive health care, as numerous medical authorities and the IOM have recognized—no matter where they work.

Some of the most vocal opposition to the inclusion of birth control as a preventive service comes from the United States Conference of Catholic Bishops (USCCB). It is worth noting that virtually all women, including 98 percent of Catholic women, use contraception at some point during their lifetimes. Moreover, the decision to use birth control should be left to the individual. Employers should not have the power to interfere in private health care decisions by withholding coverage for care. A key promise of the ACA is that women will no longer be subjected to extra charges for necessary preventive prescriptions and treatments. Birth control should not be treated any differently. Employers are entirely free to express their opposition to birth control, but that opposition should never translate into substandard preventive medical care coverage.

Opponents of contraceptive coverage without co-pays have argued for an expansion of employers who could refuse to provide coverage. These exclusions of care translate into significant hardships for our patients.

Dr. Tara Kumaraswami of Chicago cared for Mary, a 28-year-old mother of two. Mary worked 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 wanted 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, Mary found out that her insurance, because it is through her work, did not cover contraception. She was surprised and confused that, despite her doctor’s recommendation of an IUD, her insurance would not cover it. Dr. Kumaraswami met Mary when she came to her Title X clinic. Dr. Kumaraswami was able to provide Mary with an IUD through a family planning grant. However, Mary felt it was unfair that her insurance did not adequately protect her health and that she did not know in advance about the gaps in her coverage.

Pittsburgh physician Dr. Jen Russo took care of Rita, a young Catholic mother of five, while in residency. 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 a blood clot 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 Dr. Russo had spent hours with talking about caring for her five living children, her marriage, and how to handle her unplanned pregnancy, could now no longer speak or walk.

As physicians, we hope that in the future women like Mary and Rita will have insurance coverage for contraception that helps them to stay healthy. Lack of access to contraceptive coverage creates hardship for women and their families.

II. All women deserve access to contraceptives prescribed for purposes other than birth control in addition to family planning.

Several states make clear that narrow exceptions for contraceptive coverage do not apply to contraceptives that are prescribed for purposes other than birth control. For example, California mandates that employers, including religious employers, cover birth control when prescribed for the purposes of lowering the risk of ovarian cancer, eliminating symptoms of menopause, or for prescription contraception necessary to preserve the life or health of an insured woman. Hormonal birth control, in addition to preventing unintended pregnancies, helps address several menstrual disorders, helps prevent menstrual migraines, treats pelvic pain from endometriosis, and treats bleeding from uterine fibroids. Oral contraceptives have been shown to have long-term benefits in reducing a woman’s risk of developing endometrial and ovarian cancer, and short-term benefits in protecting against colorectal cancer. All women, including women who have religious employers, women in ministerial roles, and women employed by organizations affiliated with religious institutions need insurance coverage that will cover effective treatments, including hormonal contraception, for these conditions. The acceptance of inadequate health care coverage should not be a condition of working for a religious employer or agency.

Dr. Yolanda Evans of Seattle took care of Maria. Dr. Evans met Maria 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. Dr. Evans 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.

Dr. Lori Gawron from Chicago cared for Ava, a 45 year-old mother of four children. Two years ago Ava 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. However, Ava’s husband works as a facilities engineer at a Catholic hospital, and his insurance will not cover contraception for any reason. The fee for an IUD is over $1,000, an outlay that Ava and her family could not afford. Dr. Gawron 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.

Birth control pills are not just for contraception—they help manage the conditions of women like Maria and Ava as well as lower the risk for certain cancers. For a woman with a family history of ovarian cancer, a very lethal form of cancer, birth control pills are the only treatment to prevent the disease. In fact, they reduce the risk of developing cancer by half. It is unconscionable to us as physicians to conceive of an employer refusing to cover contraception for these women.

As illustrated by our colleagues, it is important to the health of patients that affordable preventive reproductive health coverage be available to every woman in the American workforce without regard to the reproductive health position of their employers. All women deserve accessible and affordable contraceptive services, no matter where she works or how much money she makes.

III. Conclusion

The Centers for Disease Control and Prevention recognized family planning as one of the singular public health achievements of the twentieth century. Yet proposals before Congress would allow companies a broad right to deprive women and their families of necessary medical coverage and services such as contraception. The “consciences” of corporations should not be elevated above the needs, consciences, and faiths of individual patients. Business entities should not trump personal, private decisions of women and their families. These proposals would have extreme consequences – not only allowing the refusal of care, but even coverage to people or groups that a corporation finds objectionable. This is medically unacceptable.

The ACA holds the promise of expanding health care coverage for millions of Americans and ensuring that all of our patients live healthier lives. Enabling employers, religiously affiliated or not, to interfere with the personal reproductive health care decisions of their employees is poor public health policy that could harm too many American women and families.

1 Institute of Medicine, Clinical Preventive Services for Women: Closing the Gaps (July 19, 2011).

2 Patient Protection and Affordable Care Act, Pub. L. No. 111-148 (Mar. 23, 2010) and Health Care and Education Reconciliation Act, Pub. L. 111-152 (Mar. 30, 2011).

3 Finer LB, Kost K. “Unintended pregnancy rates at the state level.” Perspectives on Sexual and Reproductive Health 2011;43:78-87.

4 Deschner, A., Cohen, S.A. (2003). “Contraceptive Use Is Key to Reducing Abortion Worldwide.” The Guttmacher Report on Public Policy 6(4): 7-10.

5 Testimony of the Guttmacher Institute, submitted to the Committee on Preventive Services for Women, Institute of Medicine, 2011, available for download at http://www.guttmacher.org/pubs/CPSW-testimony. pdf.

6 Gold, R.B. (2011). “Wise Investment: Reducing the Steep Cost to Medicaid of Unintended Pregnancy in the United States.” Guttmacher Policy Review 14(3): 6-10.

7 Burkman, R., Schlesselman, J.J., Zieman, M (2004). “Safety concerns and health benefits associated with oral contraception.” American Journal of Obstetrics and Gynecology 190(4): S5-22.

8 Bonnema, R.A., McNamara, M.C., Spencer, A.L. (2010). “Contraception choices in women with underlying medical conditions.” American Academy of Family Physicians 82(6): 612-8.

9 Frost, J. J. and J. E. Darroch (2008). “Factors Associated with Contraceptive Choice and Inconsistent Method Use, United States, 2004.” Perspectives on Sexual & Reproductive Health 40(2): 94-104.

10 Several measures are under consideration in this Congress including S. 2043, H.R. 3897, S. 1467, H.R. 1179 and S. Amdt. 1520 to S. 1813.

11 Jones. R.K. and Joerg Dreweke, “Countering Conventional Wisdom: New Evidence on Religion and Contraceptive Use,” Guttmacher Institute, April 2011. Among all women who have had sex, 99% have used a contraceptive method other than natural family planning.

12 An unintended pregnancy may have significant implications for a woman’s health, sometimes worsening a preexisting health condition such as diabetes, hypertension, or coronary artery disease. Institute of Medicine, supra note 1.

13 Cal. Health & Safety Code §1367.25(b)(2)(c) (enacted 1999): “Nothing in this section shall be construed to exclude coverage for prescription contraceptive supplies ordered by a health care provider with prescriptive authority for reasons other than contraceptive purposes, such as decreasing the risk of ovarian cancer or eliminating symptoms of menopause, or for prescription contraception that is necessary to preserve the life or health of an enrollee.

14 Burkman, supra note 8.

15 Id.

16 National Cancer Institute (available at http://www.cancer.gov/cancertopics/factsheet/Risk/oralcontraceptives) citing: Hankinson S.E., Colditz G.A., Hunter D.J., et al. A quantitative assessment of oral contraceptive use and risk of ovarian cancer. Obstetrics and Gynecology 1992; 80(4):708–714.