Understand the Impact of the ACA on Women’s Equity and Accessible Contraceptives

The Affordable Care Act (ACA) was signed into law in 2010. Through the ACA, many health insurance plans began providing coverage for women’s preventive health care without cost sharing.¹

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Importantly, under the ACA, any method of contraception approved by the FDA would be covered.1 Out-of-pocket costs for contraceptives noticeably decreased after the ACA required coverage, encouraging women to opt for long-acting reversible contraception insertions, a more costly but effective form of contraception.2 The proportion of unintended pregnancies decreased from 51% in 2008 to 45% in 2011, illustrating that with proper coverage, women can reap the benefits of expensive but more effective contraceptives at little to no cost.³

Despite this step in the right direction, comprehensive access to contraceptives remained limited after ACA implementation. Due to a regulation instated by the Trump administration in 2018, employers or universities with any religious or moral objection to contraception could deny coverage of birth control, lessening the authority and implementation of the ACA.⁴ Some women were unable to consider contraceptives as a viable option due to lack of health insurance.

Historically, the cost of oral contraceptives has deterred women, especially those from low-income backgrounds, from seeking out preventive care.¹ Others disproportionally affected include girls and women between 15 and 19 years of age, women of color, and women without a high school degree.³ As a result, the rate of unintended pregnancies is significantly higher in the United States than in other developed countries.³

Numerous states have attempted to target the challenges that vulnerable communities of women are likely to encounter when accessing contraception: unaffordable co-pays, lack of insurance coverage, or inability to access an authorized prescriber to obtain a prescription due to geographical location and/or financial costs. In the interest of filling gaps in coverage made by previous administrations, states began developing laws aimed at providing these groups with access to preventive services.¹ These laws take various forms, including prohibiting insurers from restricting and delaying coverage, eliminating the need for prescriptions when obtaining OTC equivalents, and allowing pharmacists to provide birth control without a prescription.¹ Some states, such as Maine, have adopted a new way of dispensing contraception: an extended supply may be routinely dispensed and covered by insurance in a 1-, 3-, 6-, or 12-month supply.⁵

Women without insurance coverage face similar barriers to accessing contraception. Ensuring there are OTC equivalents of popular, name-brand contraceptives is vital to allowing more vulnerable communities of women access to care. Some pharmacies may require a prescription for OTC contraceptives; however, certain states have waived the need for prescriptions.⁶ If a prescription is still required, many states have called for oral contraceptives to be dispensed in larger supplies, up to a year’s worth.⁶

As of January 2024, 29 states plus the District of Columbia have begun allowing pharmacists to prescribe or provide contraception without a physician’s approval.⁶ More contraceptive options are being added to the market, including OTC equivalents.⁶ With this number of states implementing changes, women from historically underprivileged communities are more likely to have increased access to preventive care and lower travel costs if geographical location is an obstacle.

Women benefit from increased access to contraception, as demonstrated by the ACA. Preventive care is essential to overall health, quality of life, and increased equity among disadvantaged communities.

About the Authors

Ayshe L. Yeter is a political science major at the University of Kentucky.

Joseph L. Fink III, JD, DSc (Hon), BSPharm, FAPhA, is emeritus professor of pharmacy law and policy as well as former Kentucky Pharmacists Association Professor of Leadership at the University of Kentucky College of Pharmacy.

References

1. Pelka A. States expand coverage of contraception. National Health Law Program. September 23, 2016. Accessed March 8, 2024. https://healthlaw.org/resource/health-advocate-states-expand-coverage-of-contraception/

2. Snyder AH, Weisman CS, Liu G, Leslie D, Chuang CH. The impact of the Affordable Care Act on contraceptive use and costs among privately insured women. Womens Health Issues. 2018;28(3):219-223. doi:10.1016/j.whi.2018.01.005

3. Unintended pregnancy in the United States. Guttmacher Institute. January 2019. Accessed March 8, 2024. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states

4. McKee C. Recap: The latest Supreme Court decision on the ACA contraceptive coverage requirement. National Health Law Program. July 13, 2020. Accessed March 8, 2024. https://healthlaw.org/recap-the-latest-supreme-court-decision-on-the-aca-contraceptive-coverage-requirement/

5. AP (WCSH). Maine passes law to allow 12-month supply of birth control. News Center Maine. June 17, 2017. Accessed March 8, 2024. https://www.newscentermaine.com/article/news/local/maine-passes-law-to-allow-12-month-supply-of-birth-control/97-449877786

6. Howard J. More US pharmacists can now prescribe birth control, and soon, some patients won’t need prescriptions at all. CNN Health. January 12, 2024. Accessed March 8, 2024. https://www.cnn.com/2024/01/12/health/otc-birth-control-pharmacist-prescribed/index.html#:~:text=More%20US%20pharmacists%20can%20now,t%20need%20prescriptions%20at%20all&text=Access%20to%20hormonal%20birth%20control,getting%20major%20changes%20in%202024