The Affordable Care Act (ACA) has lowered financial barriers to birth control by requiring health plans to cover contraceptives at no cost sharing, but restrictions limit the availability and affordability of certain methods. While we’ve come a long way in ensuring access to this essential service, one hundred years after Margaret Sanger opened the first Planned Parenthood clinic in Brooklyn, nearly half of all pregnancies in the U.S. are unplanned. Addressing the unmet need for contraceptives and enabling women to maintain consistent and accurate drug use is a public health issue that affects insurers, consumers, and providers.

Gaps in Coverage

Under the ACA, health plans must cover all FDA approved categories of contraceptive methods without cost sharing as part of the preventive services provision. Access to birth control is a critical medical concern for women who are delaying or avoiding childbearing. Expanding access to contraceptives not only allows women to control if and when they have children, but also helps women have healthier pregnancies and reduces pregnancy-related costs to the health care system. Coverage that makes birth control available at no cost sharing increases usage and reduces the unintended pregnancies, right? It’s not so simple…

Thanks in part to the ACA, the unintended pregnancy rate in the U.S. has declined since 2008. However, that rate is still one of the highest among developed countries. Why? While the ACA has helped reduce financial barriers that women face when buying birth control, other barriers exist that can make it difficult for women to maintain consistent access to contraceptive drugs and supplies.

Case in Point: The Pill 

The most common form of birth control is “the pill,” a hormonal oral contraceptive that requires a consistent daily dosage, taken at the same time each day. Used correctly, it is more than 90% effective at preventing pregnancy. Accurate use requires a constant supply – for this reason, doctors usually prescribe an annual supply of the drug. However, many insurance companies limit coverage to just a one-month supply at a time, forcing women to return to the pharmacy each month to refill their prescription. These insurer-imposed restrictions create time and cost barriers for women without transportation, in rural areas, and with work and childcare constraints.

A University of California in San Francisco study linked an increased supply in oral contraceptives to a 30 percent reduction in unintended pregnancies. The lead author of the study compared the limits on dispensing birth control to “asking people to visit a clinic or pharmacy to renew their seat belts each month.” The same study found that a decrease in unintended pregnancies would greatly reduce the financial burden on health plans and public health programs by lowering pregnancy-related costs.

States Step In: Legislation for Twelve-Month Supplies

Last month, California Governor Jerry Brown signed a measure requiring health plans to cover up to a twelve-month supply of FDA-approved, self-administered hormonal contraceptives, including the pill, patches, and rings. The law applies to both private insurance and the state Medicaid program. An analysis by the California Health Benefits Review Program found that the bill will decrease unintended pregnancies, abortions, and save about $43 million per year.

California is one of just six states where such a law has been enacted, and only five of those states ensure a full years’ supply. According to the Guttmacher Institute, in 2016 alone, 18 states have introduced a total of 32 bills to allow access to a twelve-month supply. Insurers have opposed this type of legislation, based on the logic that mandates drive up costs for their company, despite evidence that reducing unintended pregnancies would ultimately lower costs. Insurers have also raised concerns that providing an annual supply could require them to pay for contraceptives when a  woman is no longer paying for coverage; however, because many plans already cover a three-month supply, the overall costs should even out among plans if all insurers were to provide a twelve-month supply.

Wolf in Sheep’s Clothing: Over-the-Counter Pills

Insurers aren’t the only obstacle to dispensing more pill packs; many of these bills get stuck in partisan battles within state legislatures. One alternative proposed by opponents to the twelve-month supply requirement is over-the-counter (OTC) birth control. This would reduce the need for medical appointments that require time, transportation, and sometimes cost-sharing to get the prescription, effectively increasing availability and reducing unintended pregnancies, right? Again, not so fast…

Insurers only cover OTC birth control without cost sharing if someone writes a prescription. Birth control without the means to pay for it does little to expand access, and undermines the ACA’s preventive service provision to make contraceptives affordable for everyone.

There are some initiatives to provide birth control without a doctor’s prescription that still fall under insurance coverage. For example, a bipartisan bill that took effect this year in Oregon allows pharmacists to prescribe the pill. Though it’s not technically “over-the-counter,” it lowers barriers by eliminating the doctor as the middleman, and still falls under the ACA’s provision that health plans cover prescribed birth control at no cost-sharing.

The ACA has made great strides in expanding access to birth control. In the first six months of 2013, the year the birth control mandate took affect, out-of-pocket spending on the pill dropped by about half. Although these savings represent a very real liberation for millions of women who can now afford to control their reproduction, we still have a lot of work to do to bring our unintended pregnancy rate down. To build on the gains made by the ACA, policymakers need to consider all of the barriers women face in accessing care.