Reading the Institute of Medicine

Reading the Institute of Medicine July 6, 2014
Last night I read about and wrote about the contraceptive mandate.  It was striking to me that this mandate really was quite different than all other mandatory services, which were focused on screening and counseling, or a small number of specific services for at-risk groups (such as low-dose aspirin).  I read the government’s rationale as expressed in the relevant regulation issued in 2013, but I wasn’t entirely satisfied with that, so today I’ve gone to the original Institute of Medicine publication itself, in which they detail their justification for mandating that contraception be covered with no out-of-pocket cost.

Here’s the deal:  their ultimate goal is to reduce the number of unplanned* pregnancies (currently at 49% of total pregnancies) by moving more women onto IUDs and implants.  They reference this wider goal in multiple spots in the text and fit their current document into this context.

It is thought that greater use of long-acting, reversible contraceptive methods—including intrauterine devices and contraceptive implants that require less action by the woman and therefore have lower use failure rates—might help further reduce unintended pregnancy rates (Blumenthal et al., 2011). Cost barriers to use of the most effective contraceptive methods are important because long-acting, reversible contraceptive methods and sterilization have high up-front costs (Trussell et al., 2009).

(* Exactly where they set the line between “unplanned” and “neither planned nor unplanned” isn’t clear and I haven’t dug up this definition elsewhere yet, but, of course, it matters — you can’t move the needle toward more “planned” pregnancies if the pregnant women themselves don’t wish to plan their pregnancies in the way their betters want them to.)

Covering contraception in employer-sponsored plans doesn’t particularly seem like the most effective way of achieving this goal, since, as they acknowledge in their report, women for whom affordability of contraception is an issue are low-income women — and these women are exactly the ones who “fall through the cracks” and neither have employer-sponsored health insurance nor the freebies of Medicaid.  Perhaps their focus was really the plans in the exchanges which all the low-income people were expected to be buying in droves?

But how do they get from “we need to reduce the number of unplanned pregnancies” to “contraception is vital preventive healthcare”?

They start with defining “preventive services” as those which prevent a disease or condition with healthcare consequences.  Then, they say that “unintended pregnancy” is what has deleterious healthcare impacts:

The consequences of an unintended pregnancy for the mother and the baby have been documented, although for some outcomes, research is limited. Because women experiencing an unintended pregnancy may not immediately be aware that they are pregnant; their entry into prenatal care may be delayed, they may not be motivated to discontinue behaviors that present risks for the developing fetus; and they may experience depression, anxiety, or other conditions. According to the IOM Committee on Unintended Pregnancy, women with unintended pregnancies are more likely than those with intended pregnancies to receive later or no prenatal care, to smoke and consume alcohol during pregnancy, to be depressed during pregnancy, and to experience domestic violence during pregnancy (IOM, 1995).  

A more recent literature review found that U.S. children born as the result of unintended pregnancies are less likely to be breastfed or are breastfed for a shorter duration than children born as the result of intended pregnancies and that mothers who have experienced any unwanted birth report higher levels of depression and lower levels of happiness (Gipson et al., 2008). Finally, a recent systematic literature review found significantly increased odds of preterm birth and low birth weight among unintended pregnancies ending in live births compared with pregnancies that were intended (Shah et al., 2008).

I’m skeptical.  Without that key statement that they’ve controlled for age, income, etc., I think this more of a correlation with the factors that they identified as contributing to unplanned pregnancies:  “Although 1 in 20 American women has an unintended pregnancy each year, unintended pregnancy is more likely among women who are aged 18 to 24 years and unmarried, who have a low income, who are not high school graduates, and who are members of a racial or ethnic minority group (Finer and Henshaw, 2006).”

Ultimately, this is a public policy goal.  The dream, long-held by social liberals, is that if only young poor women are placed on long-lasting, no-user-error contraception, they’ll finish high school, go to college, start a career, and have one or two children when they reach their late twenties or early thirties, like all proper women should.  (Perhaps those liberals may acknowledge that these children are often not actually unwanted, but figure a bit of coercion or at least pressure will do the trick.  Whether the mass of low-income women actually want hormonal implants or IUDs is beside the point.)  The fact that this becomes a political issue for the Democrats, that women are decrying the injustice of paying for their contraception themselves, was not really part of the original calculus.

But if this is a public policy issue — why are employers being dragged into this in the first place?

Update: links to an AP article reporting on the first set of financial data on the impact of the contraceptive mandate.  Women, on average, “saved” $269 per year — which presumably means that this represents the average prescription-contraception-using woman’s cost over the year.  But there was no reported increase in the number of women using long-acting contraceptives, nor, indeed, in the rate of increase of birth control pills.  Does this mean this is a bust (defined as not hitting the IOM goal of more contraception-users)?  Probably too soon to tell.

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