New Debate Over Contraceptives and Women's Health

MS. DIANE REHM

10:06:54
Thanks for joining us. I'm Diane Rehm. The CDC reports that nearly 99 percent of sexually active women have used some form of birth control, and most have had to pay out-of-pocket for it. But new recommendations from the Institute of Medicine could change that. As part of a list of preventive health care services, the group recommends eliminating co-pays for contraceptives.

MS. DIANE REHM

10:07:30
Joining me in the studio to talk about the recommendations, Julie Waxman of the National Women's Law Center, Julie Rovner of NPR, Helen Alvare of George Mason University, and, joining us by phone, Dr. Linda Rosenstock. She is chair of the IOM committee that released the recommendations. But before we begin our discussion, we're going to hear first from U.S. Sen. Barbara Mikulski of Maryland. Good morning to you, Senator.

SEN. BARBARA MIKULSKI

10:08:13
This really big news.

REHM

10:08:14
Barbara Mikulski, are you there?

MIKULSKI

10:08:18
Barbara Mikulski is here. Good morning, Diane.

REHM

10:08:20
Good morning. It's so good to have you with us.

MIKULSKI

10:08:24
Diane, I'm excited to be here and very excited about this Institute of Medicine's series of recommendations on women's health preventive services. It was -- its aegis was an amendment that I offered during the health care debate.

REHM

10:08:42
Yes.

MIKULSKI

10:08:43
And it requires -- we wanted learned society to advise us on what we needed to have as a comprehensive women's health care prevention benefit. And their recommendations have now come out. And it will be very important to shifting -- prevent from men going only to acute care to preventive care.

REHM

10:09:13
Tell me why you felt so strongly about this and why you felt it was so important to add this?

MIKULSKI

10:09:24
Well, Diane, during the entire health care debate and the hearings, it was very clear that what I found in our hearings was that just being a woman was treated as a pre-existing condition. We were charged more and got less services for men of equal age and health care status...

REHM

10:09:48
Hmm.

MIKULSKI

10:09:49
...that often we were penalized because of being a woman. And then they tried to take our mammograms away from us. And I said no. And we offered an amendment on the floor that passed with over 70 votes, including support from great guys in the United States Senate. And it said -- it instructed the Department of Health and Human Services to turn to a learned society, to come up with a series of recommendations that would recognize women's unique health situation at all stages of their life.

REHM

10:10:34
So, now, are the recommendations from the Institute of Medicine those that you envisioned?

MIKULSKI

10:10:45
Yes, I did. What I envisioned was that the Institute of Medicine would turn and look at conditions that affected a broad population of women, that the condition to be prevented had a large potential impact on their health and well-being, but that it would be very strongly evidence-based and not ideologically-based.

REHM

10:11:09
So how significant do you think these recommendations will be to women's health generally?

MIKULSKI

10:11:18
Well, I think it'll be just fantastic. First of all, we eliminate co-pays and deductibles. It changes from -- it changes it also to prevention. It says that women are -- we're able to get an annual visit to do, like, a health care audit on what their situation is, from everything, from diabetes to menopause. And for younger women, it will also offer other services related to childbearing or family planning.

MIKULSKI

10:11:52
So it's going to have a very important impact where, first of all, being treated as a woman will be recognized for her unique healthy needs. Second, she will have access to those services that screen for those things that could disadvantage her immediately or would have long range consequences. It changes the nature of health care. It gives women an opportunity to be treated seriously by both their doctors and by their insurance companies.

REHM

10:12:24
U.S. Sen. Barbara Mikulski of Maryland, thanks for joining us.

MIKULSKI

10:12:30
Okay, Diane. And we'll talk soon.

REHM

10:12:32
Good to talk with you. Thank you. And, now, turning to you, Julie Rovner, these are simply recommendations from the Institute of Medicine. The Department of Health and Human Services Secretary Sebelius has not come out with final recommendations, is that so?

MS. JULIE ROVNER

10:12:55
That's correct. Now, there were -- in the law, it specified that there were some prevented services that would be automatically covered without cost sharing, without co-pays or deductibles. Those were the certain services that were recommended by the U.S. Preventive Services Task Force, vaccines that were recommended by the Centers for Disease Control and Prevention and certain services for children and adolescents recommended by the American Academy of Pediatrics.

MS. JULIE ROVNER

10:13:22
Then there were these Women's Health Services as were put forth by Sen. Mikulski and that were sent out for recommendation to the Institute of Medicine. Now, it is up, as you say, to the Secretary of Health and Human Services. There is every expectation that she will endorse these, and that's actually expected in the very near term within the next couple of weeks.

REHM

10:13:40
And turning to you, Dr. Linda Rosenstock, you are chair of the Institute of Medicine's committee for preventive services for women. You're also dean of the School of Public Health at the University of California, Los Angeles. I gathered this is not really free birth control for everyone. Explain.

DR. LINDA ROSENSTOCK

10:14:08
Absolutely. And good morning, everybody.

REHM

10:14:10
Good morning.

ROSENSTOCK

10:14:11
I think there's been some misimpression. I think when it comes to -- we actually recommended eight additional screenings or services, and Sen. Mikulski has already identified some of those. One that's gotten a lot of attention is the family planning services. But what people need to understand is that we're giving guidance to the department to consider whether health insurance should need to provide these services in terms of no co-payments, no deductibles, what we might call first-dollar coverage.

ROSENSTOCK

10:14:42
Indeed, most of the health insurance plans and many federal plans and state plans already require the provision of family planning services. What we're suggesting is that the evidence that these work very well to avoid the serious problem of unattended pregnancies and to promote optimal birth spacing between children is such that trying to reduce the barriers of co-payments or deductibles should be added.

REHM

10:15:10
So you're really talking about more than just birth control. You're talking about counseling for STDs. You're talking about screening for HIV. You're talking about breastfeeding support and counseling screening for domestic violence and at least one preventive health exam each year. Is that correct?

ROSENSTOCK

10:15:39
That's correct. Those were the eight listed services. And in context, what we had -- and we were very enthusiastic as a committee to be given this opportunity -- was that the Affordable Care Act really did focus on prevention for the first time in a major piece of health care legislation in the country. And that let us shift from a system that primarily is reactive to people's acute and urgent needs. We need to be reactive to people's needs.

ROSENSTOCK

10:16:02
But if we start to consider putting prevention at the forefront, the opportunity is that you're going to avoid long-term health consequences and health costs as well. So there was an existing list of services already covered in the legislation for reasons that we think made much sense. Sen. Mikulski said we need to take a particular lens looking at women's services because women in particular stand to benefit from preventive services.

ROSENSTOCK

10:16:28
They live longer. They have more chronic disease and disability. They have reproductive gender-specific issues. And for all those reasons, we need to look carefully. And we -- I think some people expect we come up with even more services. But we felt that the evidence for these eight particular services, from visits to screening for gestational diabetes, to counseling and education, including supporting breastfeeding, were all important evidence-based steps to improve women's health.

REHM

10:16:58
Dr. Linda Rosenstock, she is chair of the Institute of Medicine's committee for preventive services for women. Helen Alvare, what is your reaction to this report?

PROF. HELEN ALVARE

10:17:14
Oh, my first reaction, you know, as a woman who's a lawyer, not a doctor, is that it's terrific that they're turning their attention to preventive services for women. It's something that's long needed to be done, and even a lay person to the medicine can understand that. I did have, because of my long research in this area, a negative reaction to the recommendation that contraception, including things that, like, Ella, a FDA-approved morning-after pill...

REHM

10:17:44
Tell us about...

ALVARE

10:17:45
...that has chemicals that act more like an abortifacient, destroying an embryo after it's created. I was -- had a problem with that mostly because, over a long study of this issue, one can see there's really undisputed evidence that large-scale government push on birth control as the solution to unattended pregnancy hasn't only failed, but according to the CDC and Guttmacher Institute and the Census Bureau, it is correlated with increases in every problem that it alleges to correct.

ALVARE

10:18:17
If you look at the data over the '60s, '70s, '80s, '90s to today, increases in attention and funding to this have resulted in more non-marital pregnancies and births, more abortions, more sexually transmitted infections, and all to the great disadvantage of our poorest and minority women.

REHM

10:18:37
Helen Alvare, she is professor of law at George Mason University. When we come back, we'll hear from Judy Waxman at the women's -- National Women's Law Center.

REHM

10:20:03
And welcome back. We're talking about new recommendations from the Institute of Medicine that, as part of a list of preventive health services, would eliminate co-pays for contraceptives. Here in the studio, Julie Rovner. She's health policy correspondent for NPR, author of "Health Care Policy and Politics A-Z," and contributing editor for National Journal Daily. Also, Helen Alvare, she's professor of law at George Mason University.

REHM

10:20:45
And on the line with us, Dr. Linda Rosenstock, chair of the Institute of Medicine's committee that made these recommendations to the Health and Human Services Department. And turning to you now, Judy Waxman, what is your reaction? You've been pushing for these kinds of recommendations for years. Tell us why.

MS. JUDY WAXMAN

10:21:16
We have been pushing, as you say. I was asked to testify before the panel -- and so that's part of the pushing -- for these recommendations, for the very reasons that Sen. Mikulski stated already, that it was an oversight, if you will, for many years that women's preventive services were not looked at as seriously as others. And it was time.

MS. JUDY WAXMAN

10:21:45
And we thank her for her work on the new Affordable Care Act, in which this provision appears, to commission this independent scientific board that looked at the issue carefully and came up with these eight recommendations that we believe will be very beneficial to women's health across the nation.

REHM

10:22:09
Now, there is some concern about cost and how much cost this could add to the total health care bill. Julie.

ROVNER

10:22:25
Yes. Now, of course, these -- most of these services are already -- as Dr. Rosenstock said, all these -- most of these services are already covered. It's just a question of making it first-dollar coverage. And that's why, I think, we've all resisted the urge to use that term free. It's really first-dollar coverage. So everyone will be paying for it in their premiums rather than paying for it when you go and get it at the, you know, at the point of service.

ROVNER

10:22:51
And the idea, of course, is to encourage the use of these services, which this committee has found to be particularly cost-effective, but there is a concern for the secretary, not just with these services, but with all of the -- what she's creating, this list of essential services that every insurance policy will have to carry.

ROVNER

10:23:06
And the problem with that is that if you load up every package and make it too large, have too many "essential services," if the premiums get too big, then people won't be able to afford them. So there is a balancing act here. You want people to have a solid package of insurance to give them what they need, but you don't want those premiums to become so large that they won't be able to afford to have insurance. And that's the balance here.

ROVNER

10:23:31
Again, this is the balance with first-dollar coverage. Also, you want to spread that risk. You want people to get the services that they need. So you want them -- you want to encourage them to have these first-dollar services, but you don't want to have so many first-dollar services that you make the premiums too high.

REHM

10:23:45
Right. And, Dr. Rosenstock, what about the concerns raised by Helen Alvare?

ROSENSTOCK

10:23:54
Well, I'll agree, first of all, about the cost issue. And just to clarify that...

REHM

10:23:59
Sure.

ROSENSTOCK

10:23:59
...our committee was specifically asked not to look at costs, although we all operate in the real world and are sensitive to these issues. And when it comes to family planning services, there's a very robust section in the report about how they've been shown to be very cost-effective. And I think we have to look at unintended pregnancies through the lens of the reality in America. Fifty percent of all pregnancies in the United States are unintended.

ROSENSTOCK

10:24:22
That's an extremely high rate. It's the highest, really, in the developing -- in the developed world. Unintended pregnancies carry health risks, both for the woman, as well as for the newborn. And, certainly, we have to recognize that they're the driving cause of abortion in this country, although that's an indirect health effect.

ROSENSTOCK

10:24:43
So our view is that the reason we recommend the full array of FDA-approved services is that, with any intervention, there are harms and benefits. And the evidence is the net benefits overwhelm the harms. But then you have to individualize it. And it's up to an individual patient, with her physician, trying to decide what's the best method to use if she chooses to undertake family planning.

REHM

10:25:11
Well, Helen Alvare, I wonder, then, if you might agree with the committee that the higher use of contraceptives could help to at least reduce the issue of unintended pregnancies even in regard to, as you mentioned, the drug Ella.

ALVARE

10:25:35
You know, it seems logical, doesn't it? It's very understandable that -- especially the public would say -- if you take birth control, you don't get pregnant. You don't have a pregnancy. But we don't have to consult theory here. We have decades of numbers. And with increased government attention in this (word?) for the government funding of contraception -- I mean, our teen pregnancy rate for teens is 250 percent higher than 1960, 75 percent higher than 1970.

ALVARE

10:26:03
Our out-of-wedlock birth rate is 41 percent. Our abortions have stalled at 1.2 million. The studies, James Trussell's at Princeton, and dozens of studies, including one just out from Spain in January -- England, before that -- are showing that what happens is the market changes. Leading economists, Berkeley, University of Pennsylvania, et cetera, show that when you make birth control the prominent answer -- and you've pointed out, 99 percent of people already have access to it or have used it as sexually active persons -- you change the market for sex.

ALVARE

10:26:37
"Premarital Sex in America," Mark Regnerus' book, Akerlof, Yellen and Katz from Berkeley, Klick and Stratmann from University of Pennsylvania and George Mason have agreed, birth control elevation changes the market. It's already a saturated market. Emphasizing it as the answer is likely only to affirm the trivialization of sex and the continuing increase of these numbers. It's undisputed.

REHM

10:27:00
Judy Waxman.

WAXMAN

10:27:03
I want to repeat something that Julie said, and that is most health plans really do cover contraceptives already. There's a federal law that requires most employers to cover it. And the vast majority of plans do cover. What we have found -- and there are many studies to show -- that cost is still a barrier.

REHM

10:27:24
How much per month?

WAXMAN

10:27:27
Well, if someone is lucky enough to have insurance that covers contraceptives -- I can use my own daughter as an example. I hope she doesn't kill me for this. But she is a recent college graduate with a great job and her own health insurance, and she pays $25 a month. At her opening salary as a brand-new graduate, that's a lot. That is tough for her. Now, she is a responsible person, and she will do that.

WAXMAN

10:27:57
But you can see where many young women would find even $25 a month as really too much. And what the committee found was that if we could take care of that problem, for many women, the chance that they would use contraceptive more consistently, that they would use methods that are more expensive from the outset -- like, for example, an IUD is $600, plus a visit -- from the outset, that's way too much for many, many women to handle.

WAXMAN

10:28:35
But if all types of contraceptives are covered and women can get access without the barrier of cost, that could make a very big difference to many women.

REHM

10:28:46
Julie Rovner.

ROVNER

10:28:46
That was exactly what I was about to say. I think one of the things that bridges what Judy is saying, what Helen is saying is that one of the reasons that, yes, there's been more money put towards birth control, but there's still this problem with unintended pregnancy, is that a lot of women don't use it regularly or effectively.

ROVNER

10:29:03
The story -- one of the stories that I did this week was a woman who had been using it, did have insurance coverage, but found that she couldn't afford it and, in fact, got pregnant accidentally. So you have this problem. And I think what the committee said was that if women could afford, perhaps, the more expensive but more reliable types of birth control, that perhaps we would then reduce this problem of unintended pregnancy.

REHM

10:29:27
What about emergency contraceptives like Plan B or Ella? Julie.

ROVNER

10:29:34
Those would be covered because those are part of the FDA-approved package of contraception. But, again, that's where you get into these issues of do they act as potential very early abortions or not. That is an argument that continues to go on. Medically...

REHM

10:29:52
How are they supposed to work?

ROVNER

10:29:54
Well, medically, they say they work -- we do know they work primarily by inhibiting ovulation, so -- but if there's no ovulation, there is no fertilization. Then there is no issue. There is -- in theory, they can also work by preventing implantation of a fertilized egg. That is where you get into this question of is that or is that not, by preventing the implantation, of an abortifacient quality?

ROVNER

10:30:21
Medically, it's considered not. But, theologically, for many people, once that egg is fertilized, that is a human being. So...

REHM

10:30:28
But RU-486 is specifically not included. Is that correct?

ROVNER

10:30:33
No, it is not. That will interrupt a pregnancy once it is established, and that is not included in this recommendation. That would not necessarily be required to be covered. That is a whole different issue.

REHM

10:30:43
But what about Helen's point that with government intervention in this whole birth control issue, that pregnancies, that sexual behavior, that everything has just gone up, Julie?

ROVNER

10:31:02
Well, I have -- I, you know, I've only -- I've looked at some of the things that Helen has written. I'm not a sociologist, so I'm not sure I can -- how well I can interpret that. But, you know, and, as I said, I do see that -- you know, I can see where the possibility of -- as both sides have said, yes, you have birth control out there. But it's not -- there are financial barriers to it that perhaps people don't use it as effectively or as well as they could.

ROVNER

10:31:29
As we know there's no -- there's not a lot of male birth control out there. So it's all up to the woman or primarily all up to the woman. So I can see how what she writes is -- what both sides are saying can be true.

REHM

10:31:40
Dr. Rosenstock, talk about why the committee included all contraceptives, including Plan B and Ella.

ROSENSTOCK

10:31:53
Happy to do so, and I just want to say, sometimes, we can look at the same evidence and interpret it differently. But the committee overwhelmingly felt the scientific evidence was that contraceptions, with counseling, are very effective in reducing unintended pregnancies -- end of story. It doesn't mean that in every single person, in every single case, in every single setting. But overall, felt the evidence was just compellingly strong.

ROSENSTOCK

10:32:24
The reason that we turned to the full array of FDA-approved medicine devices is that this is just a recommendation for HHS to consider what should have first-dollar coverage 'cause we know, not just for family planning, but for a variety of services, both preventive and otherwise, that co-payments and deductibles are barriers to getting services. And in the preventive services realm, this is what we're trying to attack.

ROSENSTOCK

10:32:48
And this is where you need to individualize things. We didn't want to, nor did we think we should, be prescriptive for what's the best method for an individual woman. Some women have higher risks of cardiovascular complications from traditional birth control medications, and other approaches are necessary.

ROSENSTOCK

10:33:05
The emergency contraception pill, theological debate aside, is an effective part of the toolbox that is recommended as a birth control, not as a abortion-inducing agent -- as a birth control device.

ALVARE

10:33:21
May I comment on the use of the language theological?

REHM

10:33:23
And you're listening to "The Diane Rehm Show." Helen.

ALVARE

10:33:28
Just one little point there is it's not theological. When you're talking about the existence of an embryo, it's a health care issue. It's not a question of theology. Theology simply responds to what the facts are. And if one church teaches for or against this, it doesn't mean that one of the actions of Ella or RU-486 or a morning-after pill is not to destroy the possibility for an embryo to exist.

ALVARE

10:33:51
Second, I just wanted to add, it's not a question of misinterpreting evidence. The evidence is clear as can be. The IOM report cherry-picked when it looked at evidence regarding the relationship between government funding or more birth control and pregnancies. They didn't grapple with any of the leading studies by serious economists, sociologists, psychologists on that topic.

REHM

10:34:11
Okay. Hold it right there. Dr. Rosenstock, do you want to respond?

ROSENSTOCK

10:34:19
I'm going to stay with the original statement. We felt we looked at all of the evidence relevant to our charge, and our charge was not to include economic issues or cost. And that is part of the reason that we said, what is the evidence that the intervention, family planning, well-women visits, sexual counseling about sexually transmitted diseases, those kinds -- it was, you know, diabetes.

ROSENSTOCK

10:34:47
Whatever it was, our job was, is there evidence that this screening or service works to improve health? And we rest soundly that we identified the appropriate literature, and we searched broadly.

REHM

10:35:01
All right. Now, I want to get back to the cost. Judy Waxman, should all Americans be responsible for paying for women's contraceptives?

WAXMAN

10:35:16
I think they should. The same way they should be responsible for paying for women's mammograms and Pap smears and the other preventive services that are already included in the preventive benefit package and will someday include these new eight services mentioned by the committee.

REHM

10:35:38
Is there any indication as to, in the long-run, Julie, how much money this could actually save American taxpayers in health care cost?

ROVNER

10:35:54
I have not seen the number quantified yet. I'm sure that they're -- we will see it at some point. But, certainly, the cost of -- oh, Judy, do you have the number?

WAXMAN

10:36:05
Well, there was one study a while ago, a few years ago by The Washington Business Group on Health, which is a group that represents large companies. And their recommendation at the time to their businesses in their association was to cover contraception without co-pays. And if they didn't, the number was 15 to 17 percent. It will cost them 15 to 17 percent more if they did not cover contraceptives with no co-pays.

REHM

10:36:34
Interesting. And, Julie, didn't NPR and Thomson Reuters do a poll in April? What were they looking at?

ROVNER

10:36:46
Yes. We did. We asked the public whether they supported the requirement, basically, for coverage of -- of required coverage of contraception. It was overwhelming that the public did support this. I don't have the exact numbers in front of me, but it was...

REHM

10:37:03
Julie Rovner, she is health policy correspondent for NPR. Judy Waxman, she is at the National Women's Law Center. Helen Alvare is professor of law at George Mason University. On the line with us, Linda Rosenstock, she is chair of the Institute of Medicine's committee for preventive services for women, the group that has made the recommendations to Secretary of Health and Human Services Sebelius. And that decision will be coming soon.

REHM

10:40:03
And it's time to open the phones. We go first to Indianapolis, and to Valerie. Good morning. You're on the air.

VALERIE

10:40:14
Good morning. I have a question for your guest, Helen. She was -- when she was discussing how the correlation between increased government intervention and an increase in unintended pregnancies, I was just wondering, is it possible that we're confusing correlation and causation in this case? Because not only, since the 1980s, I think, she saw things have gone up. I mean, there's abstinence-only in sex education that makes it hard for people that don't have insurance to get access to contraception.

VALERIE

10:40:51
So I just wonder if it's not really the case that government intervention is why these things are going up and that if, in fact, people did have access to things like IUDs, which my insurance -- I was lucky enough that it's completely covered -- in fact, if we would see a decrease.

ALVARE

10:41:11
Thanks. That's a terrific question. And that's always a question when you're looking at statistics. Indeed, it's a combination of things like social customs, mores, the law, which used to penalize things in connection with sex that it no longer does. But I think if you look at -- and I'll recommend a couple of studies: Baumeister and Vohs on sexual economics, Mark Regnerus on premarital sex in America, Akerlof, Yellen and Katz in the Journal of Economics, I think, in 1966.

ALVARE

10:41:39
You'll see that they do a very convincing explanation of how it is that when sex and babies are completely dissociated, it changes the sexual market. Women feel that they have to participate or ought to or that it's expected of them in connection with relationships. Women do. There's all kinds of reasons. I think the book, "Promises I Can Keep," about non-marital births among the poor, is the best on this.

ALVARE

10:42:08
All kinds of reasons why both poor and more well-off women don't use it. And what happens is there ends up with more non-marital births, more non-marital, uncommitted sexual relations and more abortions. I think the case for causation is pretty strong if you look at the expert literature.

REHM

10:42:27
All right. Let's go to Jim in Laurel, Md. Good morning to you.

JIM

10:42:33
Hi. I have no problem with the covering birth control, but Barbara Mikulski stated that there's more money going to men's health than women's. I looked at -- I have an HMO, and I work, too. It's also, not surprisingly, since women get pregnant, but there's a lot more money going to women, even -- there's also, for instance, free breast cancer screening despite the fact you can get it free in Montgomery County. More women have health care than men.

JIM

10:42:59
And, in fact, you say women live longer. Perhaps it's -- the health care has something to do with it. But I don't know where she gets the idea that more money goes to men. I pay the same price, and there's all sorts of stuff I'm paying for. I'm sure...

REHM

10:43:11
All right.

JIM

10:43:11
...most money goes to women.

REHM

10:43:13
Thanks for calling.

ALVARE

10:43:14
Actually, one of things that the law does is, for the first time, you didn't used to pay the same price. Women actually, for a long time, paid more than men for health insurance. There's been a long history of gender discrimination. Because women have babies, women were often charged more for health insurance than men.

ALVARE

10:43:32
Women also have tended to use more health care, not so much because they've needed more health care, but because men have been not very good about getting health care, which is one of the reasons, probably, why women live longer than men. Because men have been sort of not very good about going and getting health care that they, perhaps, needed.

ALVARE

10:43:46
Women are -- when women tend to be better about getting preventive care, that's called for than men. But the gender discrimination is actually not -- no longer going to be allowed under the provisions of this law.

REHM

10:43:57
I wonder whether men's prostate cancer prevention programs might also be covered. Judy.

WAXMAN

10:44:10
Yes. They are covered -- the screening is covered as part of the United States Preventive Services Task Force list, as Julie mentioned at the top of the hour, is required by the Affordable Care Act before this new study came out on women's issues.

REHM

10:44:27
All right. And let's go to Dallas, Texas. Good morning, Ed. You're on the air.

ED

10:44:35
Hi. Thanks for taking my call.

REHM

10:44:37
Sure.

ED

10:44:38
This actually turns out to be a follow-up on the first caller for Helen Alvare. And when she talked about the outcomes from spending on birth control, she talked about how birth control, therefore, results in unwanted pregnancies and these other negative outcomes. And, of course, there's really no way to show that through a correlational study.

ED

10:45:08
It would also be possible that the government spends more money on birth control in areas where you have high levels of unwanted pregnancies and negative outcomes. So, in fact, the presence of these...

REHM

10:45:26
Oh, dear. Phone line dropped. Sorry. Go ahead, Helen.

ALVARE

10:45:31
The phenomena that you're seeing here, as explained both in the law and economics literature, sociological and psychological, is the same phenomenon you saw with things like seat belts or drugs for AIDS. It's called risk compensation, and it's a well-accepted explanation in these fields as to people moving to riskier behavior when they believe that the risk has been shut down. It's the insurance effect, if you will.

ALVARE

10:45:58
I think one of the problems I have with it is that, in part, it's -- we haven't discussed it yet, but this preventive care mandate would have no conscience protection. So all diverse voices, all voices of conscience on this, all contrary research is kind of squelched. You know, it's choked off.

ALVARE

10:46:15
People don't even get to experiment with other ways to approach the question, ways that women might be very interested in, which might involve tying sex and commitment more closely, bringing the concept of -- that children are created by sex, making sex a pretty important thing back into vogue as well.

REHM

10:46:34
Judy.

WAXMAN

10:46:35
This is about insurance and about coverage of items that the scientists feel are preventive health care for all women in this country. That doesn't mean we can't do other programs across the land about responsible behavior, about sex ed, which I think is really pretty lacking across the country in terms of many of the issues Helen raises and others about how to properly use birth control.

WAXMAN

10:47:06
But on the issue of insurance, I really think I need to go back to the science and the science tests on the panel that looked at literature. They looked at other federal policies. They looked at what is already in existence in health plans, and they came up with this great list that...

REHM

10:47:26
All right.

WAXMAN

10:47:26
...I think will help women.

REHM

10:47:27
Here is an email from Nick in Leesburg, Va., "Will the cost of covering contraceptives increase the cost of insurance? If not, there really is no argument against covering them for those such as Roman Catholics who cannot use them, can still choose not to do so. It's not as though having a plan that mandates covering contraceptives means that people are forced to start using them." Julie.

ROVNER

10:48:02
Well, it will increase it to the extent that it will be now -- be built into the premium because it will be first-dollar coverage. And as to your earlier question about costs, this is actually in the report, as the committee chairman said, they were not charged with looking at cost. But they actually did look at some of the studies that talked about cost. They said the direct medical cost of an intended pregnancy in the U.S. was estimated to be nearly $5 billion dollars in 2002, with cost savings due to contraceptive use estimated to be $19.3 billion.

REHM

10:48:30
Yes. Yes. All right, to David in Chesapeake, Va., good morning. You're on the air.

DAVID

10:48:39
Hi. Thanks for taking my call.

REHM

10:48:40
Sure.

DAVID

10:48:41
I think everyone would agree that, you know, just in general, we want to do things to help people pay for health care and, you know, kind of better their lives. But what these polls and this data doesn't show is the fraudulent and -- you know, fraudulent activity that's going on concerning the costs, once it's approved at the federal level when it gets to the state and local levels.

DAVID

10:49:06
What's happening is, you know, and why these contraceptives and, you know, birth control-type programs widely fail is because, you know, even though the overall intention is well taken, when it gets to the state and local level, and even though these polls are, you know, asking questions and seeing, you know, looking at the habits, psychology and everything of women, a lot of the women at the, say, the social service receiver programs, you know, the welfare end of it, they aren't telling the truth as to how they are really using this money.

DAVID

10:49:40
And I think that because the welfare programs have more incentives for women to be irresponsible and have kids because they can collect more money out of that, and they're really saving at the healthcare industry part of it and birth control part of it, that it really defeat this purpose. And...

REHM

10:50:00
Judy Waxman, do you want to comment?

WAXMAN

10:50:04
It's hard. I think there were -- I'm not sure what the question was exactly. But I do want to say that there is not money floating around that goes to individual people for them to buy or not buy their birth control. It's covered by their insurance or by Medicaid, which some low-income women can take advantage of, so if they need the service, they go to a health care provider, and they get it.

WAXMAN

10:50:31
So, really, no money that's going just out, and if I am responding properly to the caller's question.

REHM

10:50:39
Julie.

ROVNER

10:50:39
And the Title X program which provides birth control doesn't have anything to do with the welfare programs that give out money to people who have babies.

REHM

10:50:49
All right. To...

ROVNER

10:50:50
There'll be no incentive there.

REHM

10:50:52
Sure. To Miami, Fla. Good morning, William.

WILLIAM

10:50:56
Hi, Diane.

REHM

10:50:57
Hi.

WILLIAM

10:50:57
I sell insurance. And I think the comment that nobody considers the cost is a really bad thing here. And doing away with deductibles is another bad thing. My clients are small businessmen who try to help their employees with insurance. They want and they're demanding a cafeteria plan, and another mandate is going to push them over the cliff. These things cost money. Somebody has to pay.

WILLIAM

10:51:21
And if the idea is to wipe out the insurance market for the small businessmen, that's what we're going to do. And that's my biggest concern.

REHM

10:51:29
How so?

ROVNER

10:51:30
First of all, this is -- if we're talking about the contraceptives, most plans already cover it. And it, in fact, is mandated by federal law for most businesses. So it's not a huge cost. The difference, as we said many times, is making it first-dollar coverage.

REHM

10:51:49
Explain what that means.

ROVNER

10:51:52
What that means is, now, I want to get my contraception, and my insurance company covers it. But they'll say to me, as I mentioned to my daughter, you have to pay us $25 a month, and we'll pay the rest. Now, what would be -- the coverage is still there. It's the same. She can get the same product, but she will not have to pay the $25 a month. So where is that $25 going to come from, you might ask.

ROVNER

10:52:20
And the answer is it'll probably be spread throughout the system. Maybe drug manufacturers will get -- paid a little less for the product. Maybe the pharmacists won't make quite as much profit, and maybe there'll be a little addition into the health plan. But as we have said, if people get and use contraceptives, it actually saves money to the premiums and the system overall.

REHM

10:52:49
All right. And to Cincinnati, Ohio. Good morning, Bernard.

BERNARD

10:52:56
Good morning, Diane. I wanted to make a comment about -- because my wife and I would pay about $400 to my employer for health insurance and when we decided for her to go to contraceptives, they said we don't provide. We tried everything. All of them, and not even the pill, they don't cover anything. So what we ended up doing is, I have to pay $75 every month to get a contraceptive, which I think is unfair.

BERNARD

10:53:25
So I think this -- when they enact the law, it's going to help because people don't just want to have babies. If there are means to prevent unwanted pregnancies, I think people would do it. Most people are not irresponsible just to have babies when, you know, they can prevent it. What's -- in this case, what should I do? I mean, should I let my employer go away, you know, my insurance company go away like that? Or is there a way that I can let them cover for that?

REHM

10:53:51
All right, Bernard. Thanks for calling. Just to remind, you're listening to "The Diane Rehm Show." Julie.

ROVNER

10:54:00
Indeed, as we point out, most employers do cover contraceptives, but not all of them. And there -- and under this -- this would be a requirement, but not for grandfathered plans as we say.

REHM

10:54:10
Oh, I see.

ROVNER

10:54:10
So it will only be -- as plans change, they would have to then start covering this.

REHM

10:54:14
What about the IUD? Would that be covered?

ROVNER

10:54:17
Yes, it would. It would -- it is the requirements for all FDA-approved contraceptive devices.

REHM

10:54:22
All right. And, finally, to Stacey in Fort Lauderdale. Good morning. You're on the air.

STACEY

10:54:30
Hi, Diane, here's what I have to say. You know, I live here in Florida, and we have a very high unemployment rate. We have a lot of problems. The first thing our Republican supermajority legislator did when they got in under Rick Scott, our new governor, is to pass a whole host of the anti-choice, the anti-women's health, really, abortion rules and regulations.

STACEY

10:54:57
So, you know, what I'm trying to say here is that, I think, when it comes to anything at all -- and I'm vehemently pro-choice -- but if there is anything that smacks of abortion, science is going to be trumped by the chokehold that a very vocal minority have in this country. You know, and, yes, it is. When you do polls, it is in how you ask a question, how you pose a question.

STACEY

10:55:29
The majority of Americans do believe that a woman should have the right to, you know, reproductive freedoms and control over her reproductive biology. But we have people who are just so far to the right against it, and they have been voted into office. So what I'm saying is I hope that this science is going to be recognized, the scientist who actually came up with this, because it looks like religion, once again, is going to trump it.

REHM

10:55:56
All right. Thanks for calling. Helen.

ALVARE

10:55:58
Well, I think it is actually the other way around here. The -- this report does not contain -- and my entire specialty is looking at the relationship between what the law has done in particular issues and their impact on the family. Nobody has controverted this evidence, that because of this the change in the market for sex, mating and marriage, you have worse problems for women, not better. The market is already saturating them with contraception.

ALVARE

10:56:21
The report here, rather than religion choking off science, had science cherry-picking studies to lead to its conclusion, choking off other possible ideas, particularly ideas that might help poor and immigrant women who are suffering the most at this time.

REHM

10:56:37
One and final question for you, Helen. This comes from Aaron in Springfield, Mo. "Do you believe in birth control at all?"

ALVARE

10:56:49
The -- to me -- my specialty and the only thing I brought to the table today, and I assumed others did, too, is what we know about the relationship between what the law does here in defining freedom of care and what the conclusion is. And, I guess, if everybody here wanted to have a conversation about philosophical or theological beliefs, we could do that, too.

REHM

10:57:10
But do you belief in birth control?

ALVARE

10:57:13
I think that is a way of dodging my evidence, and I would rather someone ask a question about the evidence I've brought to the table today.

REHM

10:57:20
All right. Thanks very much for that answer. Helen Alvare, professor of Law, George Mason University, Julie Rovner of NPR, Judy Waxman of the National Women's Law Center. You heard earlier from Dr. Linda Ronsenstock at the Institute of Medicine and Sen. Barbara Mikulski. Thank you all so much. Thanks for listening. I'm Diane Rehm.
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