The Trump administration’s proposed reversal of a requirement that health insurers cover contraception relies on the work of religious researchers who dispute a fundamental public health tenet — that easier access to birth control reduces the rate of unintended pregnancies.
The proposed change to the Obama-era mandate leans heavily on the philosophy that increasing access to contraception will encourage sexual activity, while discounting newer, highly reliable forms of long-acting contraception that have been credited for reducing teen pregnancy and abortion.
“This is an ‘alternative facts’ problem that they’re latching onto,” said Dr. Jennifer Childs-Roshak, president of the Planned Parenthood Advocacy Fund of Massachusetts. “There is longstanding excellent research and science behind the fact that birth control does work.”
Thirty-year-low rates of abortion, teen pregnancy, and unintended pregnancy have all been logged in recent years. But those trends started before the Affordable Care Act began requiring most insurance plans to cover contraception for free. The government doesn’t yet have data on the rate of unintended pregnancies during the five years since the mandate took effect on Aug. 1, 2012.
Absent clear data that could demonstrate its impact, the Trump administration is arguing that contraception doesn’t present an overwhelming enough public benefit to require coverage by employers who disagree with it. Contraceptive opponents often attribute the decreasing rates of teen pregnancy and abortion to abstinence, their own educational efforts, or new restrictions being imposed at the state levels.
“In the absence of a substantive health benefit, I don’t see strong a public health reason to kind of violate the conscience rights of employers that would prefer not to cover these contraceptives,” said Michael J. New, who works for the Charlotte Lozier Institute — the research arm of the antiabortion organization Susan B. Anthony List — and whose research is cited in the new draft rule.
If the regulation takes hold, it would represent a swift government turnaround on a public health issue. Where Obamacare treated birth control as a basic matter of preventive health, the Trump proposal considers it through the lens of morality, siding with employers who object to providing it to female employees.
The regulation includes language suggesting that a family’s health care coverage could encourage a teenager to be sexually active, even if she’s not in the “sexually active at-risk population.” That’s defined as low-income, minority women ages 18 to 24 who didn’t graduate from high school and aren’t married.
“It leaves me speechless,” said Childs-Roshak. “The paternalistic overtone — that suggests that somehow providing access to birth control will make people have more sex — is like saying providing access to diabetes medication means that people are going to eat more candy bars.”
She noted that Teresa Manning, Trump’s pick to oversee family planning nationwide, doesn’t believe contraception works, and once said family planning should take place “between a husband and a wife and God.” Trump’s Health and Human Services secretary, Tom Price, denied that any women are unable to afford birth control and called the mandate “a trampling on religious freedom and religious liberty in this country.”
Advocates for reproductive rights said the government’s proposed policy change is skewed by ideology.
“It’s not mainstream at all,” said Mara Gandal-Powers, senior counsel for the National Women’s Law Center. “It’s not mainstream science and it’s also not mainstream the way people think.”
And, they say, the rule fails to account for the greatly improved reliability of forms of long-acting reversible contraception, such as intrauterine devices and implants, which eliminate human error. Some women have reported negative health effects from at least one form of permanent implant, however.
The regulatory change is aimed at ending the disputes of conscience surrounding the contraceptive mandate, which has been challenged all the way to the Supreme Court and was modified several times by the Obama administration in an effort to pass legal muster. After originally exempting only churches, the Obama administration changed the language several times to exempt other religious organizations and “closely held” companies whose principals object to contraception.
The Trump team’s rule would eliminate corporate distinctions and allow any employer to opt out of coverage.
“Very simply, it takes a woman’s most basic and personal decision — when and if to have a child — and puts it in the hands of her company and her boss,” said Childs-Roshak.
The regulatory change is independent of congressional efforts to repeal Obamacare, which failed in the Senate last week, and it is expected to move forward on its own. The change could occur anytime and would take effect as soon as it is published in the Federal Register.
The regulation also suggests that contraceptive mandates don’t affect unintended pregnancy rates, citing the experience of 28 states that had requirements before the Affordable Care Act.
“Despite the Departments’ previous view that increased contraceptive access through a coverage mandate would reduce unintended pregnancy, other data indicates that, in 28 states where contraceptive coverage mandates have been imposed statewide, those mandates have not necessarily lowered rates of unintended pregnancy (or abortion) overall,” the regulation states.
The citation for that claim: New’s paper published in the Ave Maria Law Review. Ave Maria is a Catholic law school established by Domino’s Pizza founder Thomas Monaghan as part of a Catholic community.
“I don’t hide affiliations I have,” New said, while acknowledging that they “may cause some people to view my work skeptically.”
Reproductive rights activists challenged New’s conclusions, saying previous state mandates were not analogous to the Affordable Care Act. Individual states, including Massachusetts, did require private health plans to cover contraception. But the Affordable Care Act represented a sweeping change, requiring that women could get free birth control, in every form, from almost every insurance plan in the country.
New’s paper also cited a study — co-written by Janet L. Yellen, now the chair of the Federal Reserve Board — that applied economic theories to the increasing rate of out-of-wedlock childbirth.
Published in the Quarterly Journal of Economics in 1996, the paper theorized that the advent of the birth control pill lowered the effective price of sex — and encouraged more premarital sex — by reducing the risk of an unintended pregnancy.
“The end result,” New wrote, “was more sexual activity and more unintended pregnancies.”
But New ignored the paper’s overriding policy conclusion: that out-of-wedlock births wouldn’t drop if contraception were taken away as an option, since the stigma was already gone. Reducing access to contraception would only increase out-of-wedlock births, the paper concluded.
New said he included the research “because it shows how contraceptive availability does affect human behavior.”
Adam Sonfield, senior policy manager for the Guttmacher Institute, a research organization that advocates for reproductive rights, said preventive care, including the contraceptive mandate, is designed to encourage healthy behavior. Researchers should not need to demonstrate “large-scale demographic changes in the country in order to show its value to individual women,” he said.
“No one is out there saying, ‘Should we be covering heart disease treatments unless we can prove beyond a shadow of a doubt that it reduces the incidence of fatal heart attacks in this country?’ ” said Sonfield. “That’s not the standard anything else is held to.”