At 11:14 P.M. on election night, Natalie Rose Schwartz ’18 was at a watch party with five of her housemates. As North Carolina shifted from blue to red, she started to consider something intensely personal.
“I’m not currently on birth control,” Schwartz told The Politic, “and am thinking about getting an IUD sooner rather than later.”
Schwartz is not alone. Since the election, Planned Parenthood has reported a 900 percent increase in requests for IUDs.
“It’s been an unprecedented surge,” said Kafi Rouse, the Vice President of Public Relations and Marketing for Planned Parenthood of Southern New England. “There’s been a significant increase in our appointments scheduled online for birth control, with demand for IUDs.”
IUDs, or Intrauterine Devices, are an increasingly popular form of long-term birth control. Rather than administering daily birth control pills, doctors implant a T-shaped device directly into a woman’s uterus. Paraguard, the nonhormonal copper IUD, is effective for ten years, while the four hormonal IUDs available—Mirena, Skyla, Liletta, and Kyleena—are effective for three to five years.
In other words, an IUD will last through the Trump Presidency.
“I’ve been on the pill for about five years and made an appointment to get an IUD the day after the election,” a Yale alumna, who chose to go by the pseudonym Alexa, told The Politic in an online correspondence. “Now, with conservatives in control of two (soon to be three, perhaps) branches of government, having long-term birth control felt much less like a convenience and much more like a necessary precaution.”
Other women cited cost and the potential loss of insurance coverage as factors in their decision-making.
“I’m currently taking the pill,” Rita Wang ’19 told The Politic. “Right now, I’m covered under my parents’ plan for health insurance, which covers my birth control, but if Obamacare is overturned, I would probably not be able to afford having to pay 70 dollars a month for my pill.”
Before the Affordable Care Act’s contraceptive mandate, price was a significant barrier to IUD access, with implantation costing upwards of 1,000 dollars in many states. After the bill passed, everything changed.
“Thanks to the ACA, 20 million people now have healthcare who didn’t have it before,” Rouse explained. “And the ACA requires almost all health insurance plans to cover all eighteen FDA-approved methods of birth control.” Those 18 methods include the copper IUD and at least one brand of hormonal IUD.
Under the Affordable Care Act, most insurance plans are required to cover all preventative care, including birth control, without copay. This distinction is key for patients with high-deductible plans that force them to pay out of pocket for the majority of their healthcare expenses.
“What then happens is every time you go to a doctor, you effectively end up paying because you’ve got this deductible you’ve got to meet,” Sarah Croucher, the Executive Director of NARAL Pro-Choice Connecticut, explained to The Politic. “So the way that the ACA is set up, you can go for your annual exam, and you can go to visit your gynecologist, and those things that count as preventative care are free because they are preventative care.”
Dr. Neena Qasba, a Family Planning Fellow at Yale New Haven Hospital, said that she supports the contraceptive mandate.
“It’s not perfect,” she told The Politic, “but it did ensure that contraception was covered as a preventative health benefit, and there was no cost sharing. Previously, an IUD would cost hundreds of dollars out of pocket, but under the contraceptive mandate there was no copay. If it [were] repealed, women would be footing the bill again.”
The repeal of Obamacare is not an idle threat. Despite the failure of the American Health Care Act (AHCA), the Republican party has doubled down on its promise to repeal the Affordable Care Act. After the replacement bill was tabled, House Republican Whip Steve Scalise warned Democrats that their “celebration [was] premature.”
To the relief of many, the repeal of Obamacare would not have guaranteed the repeal of the contraceptive mandate. In order to avoid a filibuster from the Democrats, Republicans framed the AHCA as a Budget Reconciliation Bill, which would only have required a simple majority in the Senate. Therefore, the Republican plan could only change those parts of the Affordable Care Act that are related to federal funds, most importantly the individual mandate and the Medicaid expansion. The contraceptive mandate does not fall into this category, since it does not involve the allocation of federal funds.
But others have pointed out a more chilling reason the Republican plan failed to repeal the contraceptive mandate: it didn’t have to.
Dr. Nora Niedzielski-Eichner LAW ’18 is a board member of “Yale Law Students for Reproductive Justice,” a group at Yale Law School that does research pertaining to reproductive care access. “When they pass big statutes like [the Affordable Care Act], they leave a lot of the details for the government agencies to figure out,” she told The Politic.
Those details usually come in the form of agency regulations, which are much easier to change than a Congressional statute. Altering them, however, still requires “notice and comment,” a procedure in which the proposed regulation is made available to the general public. The entire process can take months.
Statutes typically leave details to regulations, but the Affordable Care Act left details out of both the statute and the regulations. Instead, the law deferred the essential part of the contraceptive mandate, that “all Food and Drug Administration-approved contraceptive methods” must be covered as preventative care, exclusively to the guidelines of the Department of Health and Human Services.
And unlike regulations, guidelines can be changed without any process of “notice and comment.” That means contraceptive access can be rolled back even with the Affordable Care Act completely intact and with very little opportunity for public pushback.
“I am very angry about the fact that the Obama Administration did not put contraceptives into regulations and left them in guidelines,” Niedzielski-Eichner told The Politic. “Women’s preventative health care is too important to be treated as if it could be taken away without any review process or public input.”
“It’s low-hanging fruit,” Croucher said of the contraceptive mandate. “If they have to say that they have done something, and they need little bits of things to chip away at, that’s one of the things that they can chip away at pretty early on.”
Chipping away at the contraceptive mandate would not affect all women equally.
“It means different things to different people,” Croucher told The Politic. “For someone like me, it means that I am going to end up paying a little more for contraceptive coverage. But for people on low incomes, that could have a much more devastating effect…I think it is really important that we keep talking about the intersectionality of how changing these policies is going to continue to keep people in poverty and to make life much harder for them.”
The disparity applies not just to access to birth control but to all reproductive health care.
Rollbacks in abortion access, Rouse explained, would also have a “disproportionate impact on those who are already facing far too many barriers to healthcare, such as people of color and people who live in rural areas, and people with low incomes.”
The impact of the new administration’s agenda will also be unequal across state lines.
In blue states, reproductive rights advocates are optimistic that state governments will be able to blunt the effects of potential federal rollbacks. In Connecticut, activists mainly mourn the loss of a path to enact new progressive health care legislation.
“The things that we had on our radar, like potentially doing some little incremental things to keep improving access to contraception at no cost and to also make sure that paid family leave passed, those kinds of things seem much more unlikely in the current political climate,” Croucher told The Politic.
But Croucher remains confident that Connecticut will be able to shield its citizens from the effects of federal legislation.
“I think what is positive in Connecticut is that there is work that we can do to try and mitigate anything that comes from the federal government and to make sure that we don’t lose access and go backwards in terms of women’s health,” Croucher continued. “I don’t think that in Connecticut we are going to let people lose access to vital contraceptive services. But I think that that’s a very different case in other states.”
Dr. Qasba hails from one such state. During Qasba’s residency at Indiana University, then-Governor Mike Pence signed a bill requiring doctors to discuss with women who had just miscarried the option of burying the fetus.
“I was rolling [a patient] back to the ER and she’s bleeding and they’re like ‘You have to make her sign this form about burying her pregnancy tissue,’” Qasba said. “She had an ectopic pregnancy. We ended up talking to her about it after her surgery, because I was like ‘We’re not talking about this right now. Let’s save her life and then she can fill out a form that has nothing to do with her medical care.’”
While these stories are common in red states, in other parts of the country, access to reproductive health care, and especially to IUDs, has increased dramatically. As of April 2016, Connecticut became one of 20 states with Medicaid programs that covers the insertion of an IUD right after a woman gives birth.
“It’s a reimbursement issue,” explained Qasba, who worked on the initiative. “IUDs have always been covered, but in obstetrical care the physician gets reimbursed a certain amount for a vaginal delivery and a certain amount for a C-section. You couldn’t get extra things added on.”
Now, with a new billing code specifically designed for postpartum insertion of IUDs, women can get long acting birth control inserted immediately after delivering a baby. In the past, new mothers had to wait six weeks to discuss birth control at a postnatal visit.
For many women, that visit never happened.
“We know that women, especially those who are low resource have difficulty with transportation or social support,” said Qasba. “They are frequently unable to return for their postpartum visit where most of the contraception initiation occurs after pregnancy. If you can put in the IUD right after [childbirth] it promotes birth spacing and decreases unplanned pregnancy.”
Pregnancy is also the time when women are most likely to be insured, since many states use Medicaid to temporarily insure pregnant women who would not otherwise qualify.
But the increasing number of insurance-insecure women getting IUDs raises concerns about follow-up care and removal.
“I got the IUD this past August,” a full-time mom from North Carolina, who had purchased insurance through the Affordable Care Act healthcare exchange, told The Politic. “I had UnitedHealthcare, but last month my payment got raised to 400 dollars a month so now I don’t have insurance.” She told The Politic her doctor would charge her 400 dollars out of pocket to have her IUD removed, a price she couldn’t afford.
“Having the availability of IUDs and implants is very exciting but unfortunately, as we are going into uncertainty of coverage in the future, we need to make sure that patients have the resources to get them out when they want them,” Qasba told The Politic. “Otherwise it could become a coercive practice to give women these devices and not have the resources for them to get them out when they want to.”
Women who fall into the Medicaid gap are particularly vulnerable. The Affordable Care Act planned to insure people in two distinct ways. First, the bill required states to expand Medicaid to cover all people with incomes lower than 138 percent of the Federal Poverty Line (FPL) or risk losing Medicaid funding. Then, those making 100 percent to 400 percent FPL were given subsidies to purchase private plans on health care exchanges. But even as the Supreme Court upheld the constitutionality of the individual mandate in a five to four vote, it ruled seven to two that the federal government could not force states to expand Medicaid.
As a result, 19 states have refused to accept the Medicaid expansion. Because they are mostly red states skeptical of government spending, they are also the states that previously had the most limited Medicaid coverage. The Medicaid gap is made up of the people in those states who make too much money to qualify for Medicaid, but not enough to qualify for subsidies on the healthcare exchanges.
“In those states that don’t have a Medicaid expansion, you just have this gap of people that aren’t on subsidized private insurance and can’t afford any kind of private insurance,” Croucher explained. “The whole idea of the ACA was that you expanded Medicaid so that you had people covered by Medicaid up to a certain point, and then they started to get subsidies to go into private insurance.”
In other words, it is now possible to be too poor to qualify for health care subsidies.
Connecticut accepted the Affordable Care Act’s Medicaid expansion and does not have a Medicaid gap. But Qasba emphasized that care should be taken to protect the health care access of other vulnerable populations.
“We have a sizeable community of undocumented immigrants and when they want IUDs, that is one of the things we talk about with them, about what are their options to get them out,” she told The Politic. “No woman should feel trapped with her device that she doesn’t want anymore.”
What does it mean for women to make medical choices for political reasons?
“I think that there are good reasons why people might not want to have a baby in the next four years,” Croucher said. “I know some who are feeling doom and gloom about the idea of potentially bringing a child into the world in the Trump years, and then there are those people who are worried about having their health insurance continue to fund [their] birth control.”
“I’ve been thinking about getting an IUD for years, but put it off because I’ve been concerned about negative side effects that might come with changing my birth control method,” Alexa told The Politic. “It was never a priority, just an option that occasionally crossed my mind. After the election results came in, I jumped into action around the IUD because it felt like something I could control.”
“We have had patients who have gotten an IUD last year,” said Rouse, “and they called back just this month to say ‘Can I go ahead and get another one so that the clock will start all over?’ The Presidency is four years.”