A Focus on Contraception in the Wake of Dobbs.

Abstract

The abortion landscape in the United States changed dramatically following the ground-shaking Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade (Dobbs V. Jackson Women’s Health Organization, 2022Dobbs V. Jackson Women’s Health OrganizationSupreme Court of the United States June 2022.https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdfDate accessed: March 20, 2023Google Scholar). Although the direct result of the Dobbs ruling has been the near-elimination of abortion access in large swaths of the country, this case has also put a spotlight on the importance of contraceptive access for those who seek it. Compounding this challenge, there are forces at work that seek to roll back many of the changes that enable people to obtain the contraceptive method of their choice. Many were alarmed to see Justice Clarence Thomas raise the need to revisit the 1965 decision in Griswold v. Connecticut, which ruled that married couples have a right to use contraception, in his concurrence to the Dobbs decision given that this Court no longer interprets the U.S. constitution to grant a right to privacy (Dobbs V. Jackson Women’s Health Organization, 2022Dobbs V. Jackson Women’s Health Organization(Thomas, J. concurring), No. 19–1392 (Supreme Court of the United States June 2022).https://s3.documentcloud.org/documents/22067323/dobbs-v-jackson-womens-health-organization-clarence-thomas-concurrence.pdfDate: 2022Date accessed: March 20, 2023Google Scholar). Although this potentially existential threat to the underpinnings of the right to obtain contraception may seem like a stretch to some, proposed state and federal bills that would define pregnancy as beginning at the moment of conception could lead to some contraceptives being considered abortifacients under some state laws. The American College of Obstetrics and Gynecology (ACOG) distinguishes between conception and pregnancy, clarifying that “conception is a lay term that has no scientific validity” and that pregnancy begins after “implantation of a blastocyst” (ACOG, 2018ACOGreVITALize: gynecology data definitions.https://www.acog.org/en/practice-management/health-it-and-clinical-informatics/revitalize-gynecology-data-definitionsDate: 2018Date accessed: March 19, 2023Google Scholar). For example, the Kentucky abortion ban explicitly defines "fertilization" as the “point in time when a male human sperm penetrates the zona pellucida of a female human ovum,” and the law also has a provision in the same law that claims to exclude the provision of contraception from criminalization (Kentucky Human Life Protection Act, 2019Kentucky Human Life Protection Act.KRS. 2019; 311 (Available:): 772https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=49228Date accessed: March 20, 2023Google Scholar). It is not hard to imagine that some bans would be interpreted to block access to intrauterine devices (IUDs) and emergency contraceptive (EC) pills by claiming that they interrupt existing pregnancies, which is not accurate. A recent KFF poll found that half of women who live in states that ban abortion were not sure if EC was legal in their state (Sparks et al., 2023Sparks G. Schumacher S. Presiado M. Kirzinger A. Brodie M. KFF Health Tracking Poll: Early 2023 Update On Public Awareness On Abortion and Emergency Contraception. KFF.https://www.kff.org/womens-health-policy/poll-finding/kff-health-tracking-poll-early-2023/Date: 2023Date accessed: March 20, 2023Google Scholar). Finally, it must be acknowledged that abortion bans will likely affect the willingness of clinicians to work as sexual and reproductive health care providers in states that ban abortion. There are already well-documented shortages and maldistributions of health care workers (Chen et al., 2021Chen C. Strasser J. Banawa R. Castruccio-Prince C. Das K. Pittman P. Bodas M. Who is providing contraception care in the United States? An observational study of the contraception workforce.Am J Obstet Gynecol. 2021; 226: 232.e1-232.e11Abstract Full Text Full Text PDF Scopus (5) Google Scholar). The workforce challenges facing health care providers have been magnified for those who provide reproductive health services with policies that restrict the provision of care, unstable funding, and stigma. Many studies have documented existing contraceptive (Power to Decide, 2023Power to DecideContraceptive Deserts.https://powertodecide.org/what-we-do/access/contraceptive-desertsDate: 2023Date accessed: March 19, 2023Google Scholar) and maternity care deserts (March of Dimes, 2022March of DimesMaternity care deserts report.https://www.marchofdimes.org/maternity-care-deserts-reportDate: 2022Date accessed: March 20, 2023Google Scholar), and there have been anecdotal reports of clinicians who are contemplating moving out of states with abortion bans, citing concerns about personal safety, fears of litigation and criminalization, and being prohibited from delivering high-quality care (Novack, 2023Novack S. “You know what? i’m not doing this anymore.” Slate.https://slate.com/news-and-politics/2023/03/texas-abortion-law-doctors-nurses-care-supreme-court.htmlDate: 2023Date accessed: March 20, 2023Google Scholar). It is likely that the confluence of these factors will have a disproportionate impact on women of color and other marginalized individuals in need of contraceptive services. The anticipated impact of abortion bans on communities of color has been raised by many (Kozhimannil et al., 2022Kozhimannil K.B. Hassan A. Hardeman R.R. Abortion access as a racial justice issue.New England Journal of Medicine. 2022; 387: 1537-1539Crossref Scopus (7) Google Scholar), but what has received less attention is the potential spillover on access to and availability of contraceptive services. Although there is currently a robust foundation in the United States for financing contraceptive services, gaps in the infrastructure of contraceptive care provision persist. The new barriers that abortion bans present for those who want to prevent pregnancy are compounded by ongoing gaps in contraceptive financing, limited options and access points, and mis- and disinformation about sexual and reproductive health. Costs affect women's use of contraceptives. A quarter of reproductive-aged women and others capable of pregnancy report that they were not using their preferred contraceptive method, with 12% attributing it to affordability (Frederiksen et al., 2022Frederiksen B. Ranji U. Long M. Diep K. Salganicoff A. Contraception in the United States: a closer look at experiences, preferences, and coverage. KFF.https://www.kff.org/womens-health-policy/report/contraception-in-the-united-states-a-closer-look-at-experiences-preferences-and-coverage/Date: 2022Date accessed: March 20, 2023Google Scholar). Although cost barriers disproportionately affect those who are uninsured, some people with private coverage and Medicaid also report affordability challenges (Frederiksen et al., 2022Frederiksen B. Ranji U. Long M. Diep K. Salganicoff A. Contraception in the United States: a closer look at experiences, preferences, and coverage. KFF.https://www.kff.org/womens-health-policy/report/contraception-in-the-united-states-a-closer-look-at-experiences-preferences-and-coverage/Date: 2022Date accessed: March 20, 2023Google Scholar). The impact of affordability barriers to contraception, even those that seem minor, takes on greater importance for those who live in states with abortion bans. Today, most plans across the country cover the full cost of Food and Drug Administration (FDA)-approved prescription contraceptive drugs, devices, and procedures for women. Following years of lawsuits challenging the Affordable Care Act (ACA) coverage policy, there is still no clear coverage pathway for people enrolled in plans offered by employers with religious objections to contraception, although regulations proposed by the Biden Administration would no longer permit employers with “moral” objections to contraception from excluding contraceptive coverage from their employee plans as had been the case under the Trump Administration (Centers for Medicare and Medicaid Services, 2023Centers for Medicare and Medicaid ServicesProposed rule: coverage of certain preventive services under the affordable care act.https://www.federalregister.gov/d/2023-01981Date: 2023Date accessed: March 20, 2023Google Scholar). Furthermore, federal rules governing contraceptive coverage are inconsistent and unclear, stipulating that women should be covered for any provider-recommended contraceptive, yet also stating that plans can use medical management techniques to limit access to certain brands (Centers for Medicare and Medicaid Services, 2022Centers for Medicare and Medicaid ServicesFAQs about affordable care act implementation part 54.https://www.cms.gov/files/document/faqs-part-54.pdfDate: 2022Date accessed: March 20, 2023Google Scholar). Perhaps it is no surprise then that more than 10 years after the passage of the contraceptive coverage policy, four in 10 (41%) women and others capable of pregnancy aged 18 to 49 are unaware that most plans are required to pay the full cost of birth control (Frederiksen et al., 2022Frederiksen B. Ranji U. Long M. Diep K. Salganicoff A. Contraception in the United States: a closer look at experiences, preferences, and coverage. KFF.https://www.kff.org/womens-health-policy/report/contraception-in-the-united-states-a-closer-look-at-experiences-preferences-and-coverage/Date: 2022Date accessed: March 20, 2023Google Scholar). These inconsistencies contribute to confusion about coverage and result in women paying out-of-pocket for contraceptives that should be covered in full. Medicaid, the federally and state-financed coverage program for people in low-income households, covers 20% of reproductive-age women in the country, 40% of low-income women, and approximately one in four women of color (Gomez et al., 2022Gomez I. Ranji U. Salganicoff A. Frederiksen B. Medicaid Coverage for Women. KFF.https://www.kff.org/womens-health-policy/issue-brief/medicaid-coverage-for-women/Date: 2022Date accessed: March 19, 2023Google Scholar). State Medicaid programs must cover family planning services without any cost sharing and allow beneficiaries to seek family planning care at the participating provider of their choice. Yet, some states have skirted these requirements by excluding coverage for ECs and banning Planned Parenthood clinics from their provider networks, as they have in Texas, Iowa, and Missouri, by either withdrawing from federal funding or obtaining approval of a waiver exempting the state from following the federal Medicaid rule that requires states to reimburse any willing provider. It is conceivable that we could see more of these types of proposals under a future administration that does not support contraceptive access and abortion rights, as was the case under the Trump Administration. The Dobbs decision also effectively closes the door for any opportunity to provide Medicaid-financed contraceptive services for Medicaid enrollees who seek abortion out of state. The lack of contraceptive care following an abortion has been raised as a missed opportunity for contraceptive counseling and services (Donovan, 2017Donovan M.K. Postabortion contraception: emerging opportunities and barriers. guttmacher institute.https://www.guttmacher.org/gpr/2017/10/postabortion-contraception-emerging-opportunities-and-barriersDate: 2017Date accessed: March 19, 2023Google Scholar). Although many states have made strides in expanding postpartum contraceptive access by unbundling the costs of inserting postpartum long-acting reversible contraception for those with Medicaid-funded births (Moniz et al., 2021Moniz M.H. Bonawitz K. Wetmore M.K. Dalton V.K. Damschroder L.J. Forman J.H. Heisler M. Implementing immediate postpartum contraception: A comparative case study at 11 hospitals.Implementation Science Communications. 2021; (Available:)https://doi.org/10.1186/s43058-021-00136-7Crossref Google Scholar), providing post-pregnancy contraception to Medicaid beneficiaries who obtain an abortion out of state and are at risk for a future undesired pregnancy becomes even more difficult because state Medicaid programs do not pay for care provided in states where clients do not reside. The third leg of the contraceptive financing infrastructure stool is Title X, the national family planning program, which subsidizes clinics that offer free or low-cost contraceptives to people who have low incomes or are uninsured. In 2021, 25% of Title X clients were Black and 38% were Hispanic (Fowler et al., 2022Fowler C.I. Gable J. Lasater B. Title X family planning annual report: 2021 National summary.https://opa.hhs.gov/sites/default/files/2022-09/2021-fpar-national-final-508.pdfDate: 2022Date accessed: March 20, 2023Google Scholar). This program has been practically level-funded for two decades (Office of Population Affairs, 2023Office of Population AffairsTitle X Program Funding History. Department of Health and Human Services.https://opa.hhs.gov/grant-programs/archive/title-x-program-archive/title-x-program-funding-historyDate accessed: March 19, 2023Google Scholar), even lagging medical price inflation. Flat funding means that the value of the federal investment decreases over time as the costs of workforce, contraceptive supplies, and other services rise. In 2021, flat funding from Congress meant that several returning grantees' applications were approved for funding, but there were not sufficient funding resources to fund all grants or fund them fully (National Family Planning & Reproductive Health Association, 2023National Family Planning & Reproductive Health Association. (n.d.)Title X.https://www.nationalfamilyplanning.org/title_xDate accessed: April 5, 2023Google Scholar) Federal regulations call for participating clinics to provide pregnant clients with non-directive pregnancy options counseling (Office of the Assistant Secretary for Health, 2021Office of the Assistant Secretary for HealthOffice of the Secretary, Department of Health and Human Services.Ensuring Access to Equitable , Affordable, Client-Centered, Quality Family Planning Services, 42 CFR Part 59. 2021; (Available:)https://public-inspection.federalregister.gov/2021-21542.pdfDate accessed: March 20, 2023Google Scholar). This element of care could be compromised for clinicians practicing in Title X clinics in states like Texas, Oklahoma, and Idaho that have laws that place people who “aid and abet” abortion at risk for civil penalties under their abortion bans. The federal program is facing an ongoing legal challenge in Ohio v. Becerra, in which the attorneys general in 11 states seek to reinstate the Trump Administration's ban on abortion counseling and referral as well as disqualify family planning sites that provide abortion services (State of Ohio, 2021State of OhioState of Ohio V. Xavier Becerra, No. 1:21-cv-675 United States District Court for the Southern District of Ohio.2021Google Scholar). A KFF survey conducted in May 2022, in the months before the Dobbs decision, found that 17% of sexually active women and others capable of pregnancy do not use contraception and are not trying to get pregnant. One of the leading reasons cited for not using contraception was concerns about side effects (Frederiksen et al., 2022Frederiksen B. Ranji U. Long M. Diep K. Salganicoff A. Contraception in the United States: a closer look at experiences, preferences, and coverage. KFF.https://www.kff.org/womens-health-policy/report/contraception-in-the-united-states-a-closer-look-at-experiences-preferences-and-coverage/Date: 2022Date accessed: March 20, 2023Google Scholar). There is still a need to expand contraceptive options for people who risk becoming pregnant when they do not want to, as well as for men. Few new contraceptive products have come to market in recent years for women, and there is still nothing for men other than condoms. There are also opportunities to broaden venues for obtaining contraception. Telehealth and over-the-counter approval offer promising new outlets for contraceptive access outside of traditional brick-and-mortar clinical settings. Since the start of the pandemic, there has been a rise in use of telehealth to obtain care from clinicians (Long et al., 2022Long M. Frederiksen B. Ranji U. Salganicoff A. Diep K. Experiences with health care access, cost, and coverage: findings from the 2022 KFF Women’s Health Survey. KFF.https://www.kff.org/womens-health-policy/report/experiences-with-health-care-access-cost-and-coverage-findings-from-the-2022-kff-womens-health-survey/Date: 2022Date accessed: March 20, 2023Google Scholar). In the early days of the pandemic, some traditional clinical providers stepped up to offer telehealth visits, mail prescriptions for oral contraceptives, and teach patients how to inject Depo-Provera at home (National Family Planning & Reproductive Health Association, 2020National Family Planning & Reproductive Health AssociationInitiating telehealth in response to COVID-19: initial considerations and resources.https://www.nationalfamilyplanning.org/file/NFPRHA-Resource_Telehealth-COVID-19-Response-3.30.2020.pdf?erid=2275479&trid=ee7f09c4-fb54-41c7-8004-6adef38110c4Date: 2020Date accessed: March 20, 2023Google Scholar). During the past three years, there has also been rapid growth in the number of consumers turning to telecontraception companies to order their contraceptives through apps and websites (Frederiksen et al., 2021Frederiksen B. Gomez I. Salganicoff A. Contraception 2.0: findings of a National study of online contraception platforms. KFF.https://www.kff.org/report-section/contraception-2-0-findings-of-a-national-study-of-online-contraception-platforms-issue-brief/Date: 2021Date accessed: April 6, 2023Google Scholar). Although this avenue has gained popularity, most users—even if they have coverage—must pay out-of-pocket for membership or consultation fees, and few companies accept Medicaid. This brings us to present-day efforts to obtain FDA approval for over-the-counter availability of a progestin-only oral contraceptive pill, a move that has support from a broad swath of reproductive health professionals and advocates (Free the Pill Coalition, 2023Free the Pill CoalitionLetter From Free The Pill Coalition To FDA Commissioner Dr. Robert M. Califf. Free The Pill.https://freethepill.org/resources/letter-from-free-the-pill-coalition-to-fda-commissioner-dr-robert-m-califfDate: 2023Date accessed: March 2, 2023Google Scholar). Should the FDA grant approval, the ultimate effects of this approach will depend in part on affordability, coverage, and the extent to which other limitations such as age restrictions are applied. Current federal contraceptive coverage regulations do not require coverage of over-the-counter contraceptives (Centers for Medicare and Medicaid Services, 2023Centers for Medicare and Medicaid ServicesProposed rule: coverage of certain preventive services under the affordable care act.https://www.federalregister.gov/d/2023-01981Date: 2023Date accessed: March 20, 2023Google Scholar). Although a handful of state laws require fully insured plans to cover over-the-counter methods without a prescription, implementation of these rules remains a challenge, as they do not apply to self-insured plans (which are regulated by the federal government) and the pharmacy reimbursement systems currently in place are not well-designed to pay for over-the-counter products. Similarly, 23 states and D.C. currently allow pharmacists to prescribe and dispense hormonal contraceptive methods directly in the pharmacy, but few plans have systems in place to reimburse pharmacists for the “visit,” which is part of the reason that few pharmacists participate (Strasser and Schenk, 2023Strasser J. Schenk E. Prescribing authority for pharmacists is integral to protecting reproductive health and rights.Health Affairs Forefront. 2023; (Available:)https://doi.org/10.1377/forefront.20230317.737754Date accessed: March 20, 2023Google Scholar). There is substantial misinformation and disinformation about the use of contraceptives. Some of this is the result of deliberate disinformation campaigns and some the result of larger-scale challenges, such as limited and poor-quality sex education in many areas of the country. The Urban Institute found in 2016 that 20–40% of reproductive-age women in the United States had heard just a little or nothing at all about IUDs and implants, the most effective reversible methods (Shartzer et al., 2016Shartzer A. Courtot B. McMorrow S. Benatar S. Kenney G.M. Knowledge gaps and misinformation about birth control methods persist in 2016. (Beyond Birth Control: Family Planning and Women’s Lives). Urban Institute.https://www.urban.org/sites/default/files/publication/84046/2000918-Knowledge-Gaps-and-Misinformation-about-Birth-Control-Methods-Persist-in-2016.pdfDate: 2016Date accessed: March 20, 2023Google Scholar). Furthermore, about a quarter of women said that they did not know about the safety of these methods. More recently in 2022, just before the Dobbs ruling, nearly one-third of reproductive-age women and others capable of pregnancy (31%) did not know where to get EC pills, despite their availability at pharmacies and other retail outlets without a prescription (Frederiksen et al., 2022Frederiksen B. Ranji U. Long M. Diep K. Salganicoff A. Contraception in the United States: a closer look at experiences, preferences, and coverage. KFF.https://www.kff.org/womens-health-policy/report/contraception-in-the-united-states-a-closer-look-at-experiences-preferences-and-coverage/Date: 2022Date accessed: March 20, 2023Google Scholar). In a 2023 poll, two-thirds of women of reproductive age incorrectly stated that EC pills can end a pregnancy in its early stages, with higher shares of confusion found in states where abortions are banned (Sparks et al., 2023Sparks G. Schumacher S. Presiado M. Kirzinger A. Brodie M. KFF Health Tracking Poll: Early 2023 Update On Public Awareness On Abortion and Emergency Contraception. KFF.https://www.kff.org/womens-health-policy/poll-finding/kff-health-tracking-poll-early-2023/Date: 2023Date accessed: March 20, 2023Google Scholar). More broadly, there is also conflation of contraception with abortion in multiple sectors of society. The “belief” that certain contraceptive methods were abortifacients was at the root of the Hobby Lobby case challenging the ACA contraceptive coverage mandate, where Hobby Lobby's owners objected to the requirement that their employees' health plan cover IUDs and EC because they believed them to be abortifacients. Similarly, Texas sought and received federal permission to exclude EC from its Medicaid-funded family planning program, and shortly after the Dobbs decision was issued, the University of Idaho announced they were no longer dispensing contraception (Boone, 2022, September 27Boone R. Idaho universities disallow abortion, contraception referral. AP NEWS.https://apnews.com/article/abortion-health-legislature-idaho-birth-control-bd238c572da10d812ef5ba93f1860fc5Date: 2022Date accessed: March 19, 2023Google Scholar) and the Truman Medical Center in Missouri stated they were going to cease distribution of Plan B pills because they were concerned about running afoul of the states' abortion bans (Hawley, 2022Hawley S. Major health system stops, then resumes Plan B amid Missouri’s abortion ban ambiguity. NPR.https://www.npr.org/sections/health-shots/2022/06/29/1108682251/kansas-city-plan-bDate: 2022Date accessed: March 20, 2023Google Scholar). This decision was ultimately revoked but contributed to the confusion about contraceptive availability and mechanism of action. In December 2022, more than 20 years after their approval, the FDA changed labeling to clarify that Plan B pills do not block implantation and are not abortifacients. Most people seek information about contraception from clinicians, and counseling is an important component of contraceptive care. Yet, just four in 10 contraceptive users rate the counseling they received as “excellent” on all four items of the person-centered contraceptive counseling measure (Frederiksen et al., 2022Frederiksen B. Ranji U. Long M. Diep K. Salganicoff A. Contraception in the United States: a closer look at experiences, preferences, and coverage. KFF.https://www.kff.org/womens-health-policy/report/contraception-in-the-united-states-a-closer-look-at-experiences-preferences-and-coverage/Date: 2022Date accessed: March 20, 2023Google Scholar). But informational needs begin well before the clinician's office. Sex education is decentralized in the United States, with great regional variation in standards and content (Neelan et al., 2022Neelan T. DeLisle D. Zief S. Launching a National sexual risk avoidance education program: title V State SRAE Program Plans (OPRE Report No. #2022-90). (Sexual Risk Avoidance Education National Evaluation).https://www.mathematica.org/download-media?MediaItemId=%7B90B37DB8-B2D3-4FD8-9D94-4BB1FADF057B%7DDate: 2022Date accessed: March 21, 2023Google Scholar). Only 20 states and D.C. require information about contraception when sex education is taught (Guttmacher Institute, 2023Guttmacher InstituteSex and HIV education. guttmacher institute.https://www.guttmacher.org/state-policy/explore/sex-and-hiv-educationDate: 2023Date accessed: March 20, 2023Google Scholar). Furthermore, there are still federal funds available for “education” that emphasize abstinence under the Title V Sexual Risk Avoidance Education grant program (Family and Youth Services Bureau, 2020Family and Youth Services BureauTitle V state sexual risk avoidance education: fact sheet.https://www.acf.hhs.gov/fysb/fact-sheet/title-v-state-sexual-risk-avoidance-education-fact-sheetDate: 2020Date accessed: March 19, 2023Google Scholar) despite evidence showing the harms of abstinence-based education that excludes information about contraception (Santelli et al., 2017Santelli J.S. Kantor L.M. Grilo S.A. Speizer I.S. Lindberg L.D. Heitel J. Ott M.A. Abstinence only until marriage: an updated review of U.S. policies and programs and their impact.Journal of Adolescent Health. 2017; 61: 273-280Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar). Many barriers to contraception are not new, but the stakes are higher in the wake of Dobbs, where in large parts of the country abortion is no longer available. The disproportionate challenges in obtaining abortion that face communities of color and people in low-income households residing in states that ban abortion may also be replicated when it comes to contraceptive access.