Credit: UC Irvine on Flickr, under Creative Commons (CC BY-NC-ND 2.0)
(WOMENSENEWS)– The key to preventing abortions, clearly, is to prevent unwanted pregnancies. Today we have excellent methods for doing that. But too many women cannot afford those methods, and roadblocks to access birth control are being erected, often by the same people who want to ban abortions.
Today contraception is not available to all American women largely because over the last decade it has been, and continues to be, under attack by local and national politicians and civic organizations. In particular, laws aimed at closing women’s health clinics, such as Planned Parenthood, have put reproductive health services out of reach for many women, especially poor women.
As of Aug. 1, 2012, however, the Affordable Care Act (aka “Obamacare”) began to take effect, mandating comprehensive preventive health care for women, including contraceptive services, without copays. In reality, as of that date, only a very small percentage of women actually had copay-free services and this benefit will not apply to all women. Moreover, access to contraception at no cost is being contested by religious groups. If the law is allowed to stand as it is at the time of this writing, we should see a drop in the rate of unwanted pregnancies and abortion.
Recently I was sitting at the desk in my exam room, writing a note in the chart of the patient I had just seen, Marina J. I work in a large pediatric practice in a low-income neighborhood in New York City. Our office is a storefront on a busy shopping street. With our brightly painted walls, it is a welcoming place for children and teens. Marina is a 13-year-old who had come in with her mother because her periods were very heavy. She usually stays home from school on the first day of her period because she is so worried about bleeding through her clothes.
After examining her and ordering some blood tests, I prescribed the best treatment for Marina’s problem: oral contraceptives. She and her mother were relieved that a remedy was available for her heavy periods and left smiling, the prescription safely tucked in Mrs. J’s purse. Marina got her pills and was able to attend school when she had her period.
Her situation was similar to 12-year-old Yennifer R’s. Yennifer’s mother brought her in a few months ago because Yennifer “had had her period for six months!” Mrs. R had been very ill and was unable to bring her in to be seen. At least Mrs. R bought iron pills for Yennifer so she wasn’t critically anemic, but Yennifer was tired all the time and very pale. I ran some blood tests and told Yennifer to keep taking the iron, but also to start taking the birth control pills I prescribed. Yennifer’s bleeding stopped in two days. She is now a much healthier girl. My point is this: if Yennifer’s family got their insurance through a Catholic organization, they would not have been able to get the birth control pills. Is that consistent with anyone’s view of what is right?
The next patient to come in, Jasmine S., was an 18-year-old college freshman. She and her boyfriend had begun having intercourse. She told me that he is her first sexual partner. They use a condom most of the time, but she knows that she is at risk for pregnancy. (She said that her boyfriend saw his doctor and was tested for HIV and other sexually transmitted infections.) After I examined her, we chatted about the birth control methods that are currently available. She decided that the contraceptive ring would work best for her. I prescribed the ring and urged her to continue using condoms, because like the pill, the ring does not offer any protection against infections. I told her how to use both methods, and the important role of each in assuring her reproductive health.
Two weeks later, Jasmine came in for a scheduled appointment, to review the results of the lab tests we had done. When I asked her how she liked the ring, she told me she could not get it. The pharmacist had written something on the back of the prescription. She handed it to me and I saw that he had written “P/A.” Not knowing what that meant, I called the pharmacist. He told me that she needed a prior authorization from her insurance company.
I thought I had heard wrong. Yes, we needed a prior authorization when my 6-month-old granddaughter needed neurosurgery and my 8-year-old daughter needed eye surgery. But prior authorization to get the ring? This made no sense to me. I called her insurance company, a Catholic Medicaid HMO in New York. The agent asked me if the patient needed the ring for contraception or some other reason. I told her that I did not want to discuss the patient’s private information with her. She responded that without such information, the patient could not get the medication.
It turns out that even with that information, the patient could not get the medication. With Jasmine’s permission, I told the woman on the phone that it was for contraception. It seems honesty may not always be helpful when it comes to obtaining reproductive health care. Because her HMO is a Catholic company, it does not pay for contraception. But Jasmine never asked to be put in a Catholic HMO; she was just assigned to that insurance plan. The insurance agent told me that another company pays for contraception for their patients. I spent a half hour on the phone with the other company. It was a long and difficult road to get a simple prescription. It was trying even for me, and I know how to navigate the health care system. Jasmine would probably never have gotten her contraception if I had not intervened.
The barriers have become insurmountable for Jasmine and many patients like her. This is simply not the way to provide health care, or to prevent unwanted pregnancies and abortions. I cannot think of a parallel situation in which men or children are denied access to needed medication because of the religious affiliation of their insurance company.
In the late 20th century it would have been impossible to predict how far the pendulum would swing in the early 21st century, returning us to a time when women’s reproductive health was imperiled. In the late 1980s, sociologists predicted that Western nations would follow a secular trend, with more self-determination and less control by religious and political institutions over private aspects of life. That prediction was accurate for Western Europe, but spectacularly off the mark for the United States.
Today we live in a country where, despite medical breakthroughs in contraceptive technology, modern means of contraception are simply not available to all women. Only 21 states mandate comprehensive insurance coverage for contraception. Poor women in states that do not require insurance companies, including Medicaid, to cover contraceptives often cannot access the means to prevent pregnancy.
Although all events reported in this book are real, all names and identifying details about Roye’s patients were changed to protect the privacy of the people involved. Some of the situations presented are amalgams of multiple women who had similar situations.
Carol Roye is a professor of nursing, a researcher and a pediatric nurse practitioner with a practice in adolescent reproductive health. She has been featured on numerous radio, television, print and media outlets, including the New York Times, and recognized as a leading expert on adolescent and women’s health issues.
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