AAFP Supports ACA's Coverage of Contraceptive Services

Academy Joins ACOG, AAP in Comments to HHS Secretary

September 28, 2016 03:45 pm News Staff

The AAFP has joined the American Academy of Pediatrics (AAP) in signing on to a letter(4 page PDF) spearheaded by the American Congress of Obstetricians and Gynecologists (ACOG) that expresses the organizations' support for the Patient Protection and Affordable Care Act's (ACA's) contraceptive coverage requirement. The letter was sent to HHS Secretary Sylvia Burwell on Sept. 20.

[Doctor holding contraceptive prescription, talking to female patient]

The letter responded to a joint request for information (RFI) from HHS, the Department of Labor and the Department of the Treasury that was published in the July 22 Federal Register.(www.gpo.gov) Comments in the letter address the departments' questions regarding "whether modifications to the existing accommodation procedure" could negatively affect women of child-bearing age and their families.

Issue Background

The HHS request stems from an opinion the Supreme Court handed down in Zubik v. Burwell,(www.supremecourt.gov) which explored questions related to whether religious institutions other than churches should be exempt from the ACA's contraceptive mandate. That mandate requires these institutions to cover certain contraceptives for their female employees.

Story highlights
  • The AAFP has signed on to a letter to HHS Secretary Sylvia Burwell supporting the Patient Protection and Affordable Care Act's (ACA's) birth control coverage requirement.
  • The letter was sent in response to an HHS request for information that was published in the Federal Register on July 22.
  • HHS' request stems from a Supreme Court case that explored questions related to whether religious institutions other than churches should be exempt from the ACA's contraceptive mandate.

According to the RFI, the three departments had previously issued regulations that offered an accommodation for eligible organizations that object to providing coverage for contraceptive services on religious grounds. The accommodation states that an eligible organization "does not have to contract, arrange, pay or provide a referral for contraceptive coverage."

"Under the departments' regulations, an eligible organization may invoke the accommodation by self-certifying its eligibility" to do so, the RFI noted. The seven petitioners whose cases were consolidated into Zubik v. Burwell, however, claimed that the requirement to provide this notice violated their religious freedom.

After reviewing supplemental briefs that the court directed the petitioners to file addressing "whether contraceptive coverage could be provided to petitioners' employees, through petitioners' insurance companies, without any such notice from petitioners," the Supreme Court ruled on May 16 that all the cases be remanded to their respective appeals courts for reconsideration.

On July 21, the Obama administration asked the respective courts of appeal to allow 65 days for advice and comment from third parties on the issue.

Joint Letter's Position

"We strongly believe that all individuals of reproductive age should have access to affordable birth control and that insurance coverage should provide for all FDA-approved contraceptive methods -- just as insurance coverage extends to other preventive care, including crucial immunizations for children," the groups said in their letter.

The CDC has named birth control as one of the top 10 public health achievements of the past century, the letter stated. And HHS has estimated that currently more than 55 million adolescent girls and women saved more than $1.4 billion in out-of-pocket costs for birth control pills in 2013 alone as a direct result of the ACA's contraceptive requirement.

In addition, the medical groups emphasized the importance of women receiving coverage of contraception without barrier or cost. "The existing accommodation adequately meets women's need for seamless, coordinated and comprehensive care in a matter consistent with both the spirit and the letter of the ACA," said the letter. "We do not believe that further alternatives to the existing accommodation are necessary, and in fact, we believe such additional accommodations would serve to hinder access to seamless care for women."

Patient-physician Relationship

The letter noted that the existing accommodation protects the patient-physician relationship and ensures that physicians and patients continue to collaborate to share responsibility for patients' health -- an essential role.

"This is particularly true given the highly personal nature of the reproductive health and family planning services that are at issue here," the letter said. "Prescribing birth control is typically far more intimate and intrusive than signing a prescription pad."

Furthermore, the letter stated, after determining that a particular birth control method is not contraindicated, a pelvic exam is required to prescribe a diaphragm or cervical cap or to insert an intrauterine device. An exam also may be indicated when prescribing other types of contraceptives, depending on a woman's medical history.

"Women should be able to make these personal decisions -- decisions that often require sharing intimate details of their sexual history and family planning -- with (physicians) they have sought out and trust."

Proposed Alternatives

The alternatives that opponents of the accommodation have proposed would remove contraceptive care from women's routine health services and instead require them to use a two-tiered system of access and coverage -- one for their overall health needs and one limited to contraceptive care.

All of the proposed alternatives would dictate to one degree or another that contraceptive coverage would be provided outside of a woman's regular health services -- whether through separately obtained insurance coverage, through care provided only at designated facilities or by requiring a cash outlay that may or may not be reimbursed through a tax credit.

"None of the alternatives proposed most often by opponents of the existing accommodation do what the accommodation does: provide plan beneficiaries with cost-free contraceptives from their pre-existing health insurance plan," the letter said.

Health Risks of No Coverage

A lack of insurance coverage for contraceptives could deter women from choosing a higher-cost option that might be the best method for them, said the groups' letter, possibly resulting in use of alternative methods that place them at risk for medical complications or improper or inconsistent use, with the additional risk of unintended pregnancy.

The letter also pointed to the numerous scientifically recognized benefits of contraceptive use in addition to preventing pregnancy, such as hormonal birth control to prevent menstrual migraines, treat pelvic pain from endometriosis and decrease the need for hysterectomy by reducing heavy menstrual bleeding.

Additionally, said the groups, "Oral contraceptives have been shown to have long-term benefits in reducing a woman's risk of developing endometrial and ovarian cancer, protecting against pelvic inflammatory disease and certain benign breast disease and protecting against colorectal cancer in the short-term."

Conversely, when contraception is harder to obtain, women have more frequent pregnancies that are more closely spaced and are at a significantly greater risk for permanent physical health damage. "Such damage can include organ prolapse that can lead to pain, incontinence and surgical treatments," said the letter.

Finally, a decision to alter the current accommodation for contraceptive coverage could have negative consequences on other key preventive services.

"Currently, the ACA requires employer‐based health plans to cover other preventive services without cost, including vaccines," the letter said. "If the current accommodation for contraceptive coverage is weakened, similar arguments may be made for vaccines and other preventive services, reducing their use by children and families by increasing the financial burden of receiving such care."

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