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NARAL: Reproductive Freedom & Choice


Access to highly effective contraception is important to improving women's overall health and in reducing unintended pregnancy and should be included as part of basic health care coverage.1 Today, almost three-fourths of U.S. women of childbearing age rely on private, employer-related plans for their health coverage. Yet, while most health insurers generally cover prescription drugs, most insurers exclude some or all prescription contraceptives.2 Therefore, as a result of insurance exclusions some women covered by private health insurance are likely to use less expensive contraceptive methods as an alternative to paying high, out-of-pocket expenses for more effective prescription contraception.

Half of All Employees in Traditional Fee-for-Service Insurance Plans Cover No Reversible Contraceptive Methods at All, and Existing Coverage is Lacking

  • Forty-nine percent of all typical large group plans (insured indemnity plans written for 100 or more employees) do not routinely cover any contraceptive methods, and only 15 percent cover the five primary reversible contraceptive methods: oral contraception, IUD insertion, diaphragm fitting, Norplant insertion, and Depo-Provera injection. Fewer than 40 percent of typical large group plans routinely cover any one of these five methods.3 Coverage of all five methods is critical to women’s health since not all methods are appropriate for all women. For instance, some women cannot take hormonally-based contraceptives such as "the pill," and they must have access to other effective contraception such as diaphragms or IUDs.4
  • Sterilization is generally covered by 85 percent of large group plans, reflecting the tendency for health insurers to cover surgical services, but not preventive care.5

Health Maintenance Organizations (HMOs) Provide Better Contraceptive Coverage, but Fewer Than Half Cover the Five Most Commonly Used Methods

  • Although 93 percent of HMOs cover some contraceptive methods, only 39 percent routinely cover the five most commonly used methods.6
  • Coverage of contraceptive devices by HMOs varies. Implant insertions are covered by 59 percent of HMOs and 86 percent of IUD insertions are covered. The devices themselves, however, are less frequently covered.7

Preferred Provider Organizations (PPOs) and Point-of-Service (POS) Networks Often Include Some Contraceptive Care, but Contain Significant Coverage Gaps

  • Forty-nine percent of PPOs and 19 percent of POS networks do not routinely cover any reversible contraceptive methods. Only 18 percent of PPOs and 33 percent of POS networks typically cover the five most commonly used methods.8
  • PPOs provide minimal coverage of contraceptive devices, with only 23 percent for diaphragm fittings, 25 percent for IUD insertion, and 35 percent coverage for injections. Coverage of contraceptive devices by POS networks ranges from 46 percent for IUD insertions and diaphragm fittings to 72 percent for an injection.9

Individual State Studies Have Found Similar Inequities in Insurance Coverage for Contraception

  • A survey of health insurers in Connecticut found that only 39 percent cover oral contraceptives, 33 percent cover Depo Provera, 29 percent cover diaphragms and cervical caps, and 43 percent cover Norplant.10
  • A Pennsylvania survey found that fewer than one-third of all insurance companies in that state cover the five most commonly used methods of prescription contraception. Moreover, nearly one quarter of all insurance companies in Pennsylvania do not cover any of the five most commonly used methods of prescription contraception.11
  • According to a Washington state survey, half of all health insurance plans in Washington do not cover any contraceptive services. Fewer than one-third of surveyed plans routinely cover the five most commonly used methods of prescription contraception. Furthermore, approximately 78 percent of eligible women are not receiving contraceptive coverage through their health plans.12
  • An Illinois survey of fifteen health insurance plans, including seven of the largest plans in the Chicago area serving more than 1.7 million enrollees, found that only 47 percent of the plans provide coverage for the five most commonly used forms of contraception.13

Inequities in Insurance Coverage for Prescription Contraception Fall Heavily on Women

  • Women of reproductive age spend 68 percent more than men on out-of-pocket health care costs, with reproductive health care services accounting for much of the difference.14
  • According to the State of Hawaii Health Department, an estimated 77 percent of privately insured women of reproductive age in Hawaii are not covered for all contraceptive services.15
  • The most effective forms of prescription contraception are used only by women. Some of these methods are expensive, at least up front, often costing hundreds of dollars at the outset of patient use.16 Thus, women who pay out-of-pocket may opt for less expensive and sometimes less effective methods, thereby increasing the number of unintended pregnancies.

Public Polls Indicate that the Public Supports Contraceptive Equity

  • A national survey by the Kaiser Family Foundation found that 75 percent of those surveyed favored legislation requiring insurers to provide coverage for the full range of contraceptives. Support for insurance coverage of contraception remained high (73 percent) even when participants were told that the coverage could increase insurance premiums by $1 to $5. In addition, the survey also found that the public is more likely to support insurance coverage of contraceptives (75 percent) than Viagra (49 percent).17
  • Three state polls found similar support. A Connecticut survey found that 76 percent of those polled support legislation requiring insurance companies to cover contraceptives.18 In New York, a poll found that almost 70 percent of registered New York voters believe health insurance prescription drug plans should be required to include birth control.19 In Texas, a Scripps Howard poll found that 61 percent of likely voters favored requiring insurance companies to cover prescription contraceptives in the same way they cover other prescription drugs.20

Improved Access to and Use of Contraception Would Save Insurers and Society Money by Preventing Unintended Pregnancies

  • Nearly 50 percent of pregnancies are unintended, including 31 percent of pregnancies among married women. Fifty-four percent of unintended pregnancies end in abortion.21
  • Improved access to and use of contraception would save insurers and society money by preventing unintended pregnancies.22 Insurers generally pay the medical costs of unintended pregnancy, including ectopic pregnancy ($4994), induced abortion ($416), spontaneous abortion ($1038), and term pregnancy ($8619).23 Therefore, access to contraception should actually prevent other, more expensive medical conditions associated with unintended pregnancy that usually are covered by health plans. In fact, a study of claims under the Utah Public Employees Health Plans (PEHP) suggests that coverage of contraceptives appears to increase their use and decrease health care utilization due to adverse pregnancy outcomes.24
  • A cost analysis conducted for The Alan Guttmacher Institute (AGI) indicates that the cost of covering contraception is not significant. The added cost for employers to provide coverage of the full range of reversible contraceptives is approximately $1.43 per employee per month. The cost is significantly lower for health plans that currently cover at least some contraceptives.25

Private Health Insurance Coverage for Contraception Will Improve the Health of Women and Families

The average woman who wants two children will spend five years trying to get pregnant and more than 20 years trying to avoid pregnancy.26 During these 20-plus years, most women will use contraceptives to avoid getting pregnant, making contraceptives an important element of women’s basic health care needs. As the American College of Obstetricians and Gynecologists (ACOG) stated, "[t]o ignore the health benefits of contraception is to say that the alternative of 12 to 15 pregnancies during a woman’s lifetime is medically acceptable."27 The lack of adequate private insurance coverage for contraceptive services makes it more difficult for women to prevent unintended pregnancy and increases the need for abortion. The majority of American women and men believe that the cost of birth control and the inability to obtain it contribute to the problem of unplanned pregnancy.28 The U.S. differs from countries with lower rates of unplanned pregnancy in that highly effective contraceptive care in the U.S. is neither widely available nor easily accessible.29

In addition to contributing to high rates of unintended pregnancy, the inaccessibility of more effective contraceptive methods carries appreciable health risks for women and children. Research shows that women with unintended pregnancies are less likely to obtain timely or adequate prenatal care. Moreover, unintended pregnancy increases the likelihood of low birth weight babies and infant mortality.30 Estimates show that effective family planning could reduce the rates of low birth weight and infant mortality by 12 percent and 10 percent, respectively.31

Requiring private insurance to cover contraception will increase access to more effective contraceptive methods and will allow a greater number of women to plan, space, and time pregnancies, thereby reducing unintended pregnancy and the need for abortion. The impact of contraceptive coverage will be improved health for American women, men, and families.

Legislators Recognize the Importance of Insurance Coverage for Contraception

Contraceptive Coverage Bills

In the last few years, more lawmakers have considered legislation to require contraceptive coverage in private insurance. For instance, from 1997 through 1999, the number of contraceptive coverage bills introduced in the state legislatures increased by 379 percent.32

Since 1998, 13 states have enacted laws to address the imbalance in prescription contraceptive coverage in private insurance: California, Connecticut, Delaware, Georgia, Hawaii, Iowa, Maine, Maryland, Nevada, New Hampshire, North Carolina, Rhode Island, and Vermont.33 Six other states have laws, policies, or regulations that provide some level of private insurance coverage for contraception (ID, KY, MN, NJ, TX, WY).34

The Need for Federal Legislation Remains

Although state laws will help many women, they cannot ensure coverage throughout the United States. Not all states will require coverage, and even in states that do, not all women who have private insurance will be covered. In fact, over half of all U.S. workers are covered under a health insurance plan regulated by the Employee Retirement Income Security Act (ERISA) and thus exempt from state regulation.35 Federal legislation will be necessary to ensure nationwide private health insurance coverage for contraception.

The Equity in Prescription Insurance and Contraceptive Coverage Act (EPICC), which would require parity in coverage for contraceptive prescriptions and medical services under those plans not subject to state regulation, was introduced in both the 105th Congress and the 106th Congress, but has not yet been brought to the House or Senate floor.36 This type of legislation is critical to ensuring more equitable private health insurance coverage, and in eliminating barriers to more effective family planning.


1. Rachel Benson Gold, Jacqueline E. Darroch, and Jennifer J. Frost, "Mainstreaming Contraceptive Services in Managed Care – Five States’ Experiences," Family Planning Perspectives, vol. 30, no. 5 (Sept./Oct. 1998): 204. In 1998 -- and again in 1999 -- Congress took an important step forward in providing equitable coverage for contraception in federal employee health benefit plans, and some states have ensured that women covered under state employee health benefit plans have contraceptive coverage. 145 Cong. Rec. H 5612-01, 5619, FY 2000 Treasury, Postal, and General Government Appropriations Act, Pub. L. 106-58, § 635; The NARAL Foundation/NARAL, Insurance Inequities: A State-By-State Review of Contraceptive Coverage, 1999 (Washington, D.C.: The NARAL Foundation/NARAL, 1999), 13. The same arguments set forth in this memorandum regarding private insurance apply with equal vigor in the public employee insurance context.

2. The Alan Guttmacher Institute (AGI), Uneven and Unequal: Insurance Coverage and Reproductive Health Services (New York: AGI, 1994), 9.

3. AGI, Uneven and Unequal, 12, 15. A 1999 survey of employers found that although 96 percent of employees in traditional insurance plans have prescription drug benefits, only 54 percent have coverage for oral contraceptives. An even smaller percentage of employees -- 39 percent -- have coverage for oral contraceptives and Norplant, IUDs, and diaphragms. Kaiser Family Foundation (KFF)/Health Research Education Trust (HRET), Employer Health Benefits: 1999 Annual Survey, (Washington, D.C.: KFF, 1999), 84.

4. Oral Contraceptives are generally not recommended for women with the following characteristics: smoker, sedentary, overweight, over 50 years of age, history of heart or vascular disease, diabetic, or high cholesterol level. Robert A. Hatcher et al., Contraceptive Technology, (New York: Irvington, 1994), 235.

5. AGI, Uneven and Unequal, 17-19.

6. Rachel Benson Gold and Cory L. Richards, Improving the Fit: Reproductive Health Services in Managed Care Settings (New York: AGI, 1996), 14. According to the 1999 KFF/HRET survey, while 80 percent of employees in HMOs have coverage for oral contraceptives, only 58 percent of these employees also have coverage for Norplant, IUDs, and diaphragms. KFF/HRET, Employer Health Benefits, 84.

7. Benson Gold and Richards, Improving the Fit, 14.

8. AGI, Uneven and Unequal, 17. The 1999 KFF/HRET survey of employers found that although nearly two-thirds (64 percent) of PPO plans cover oral contraceptives, fewer than half (44 percent) provide coverage for Norplant, IUDs, and diaphragms. As for POS networks, 67 percent provide coverage for oral contraceptives, but only 60 percent provide coverage for Norplant, IUDs, and diaphragms. KFF/HRET, Employer Health Benefits, 82, 84.

9. AGI, Uneven and Unequal, 15.

10. Connecticut NARAL survey, "Comprehensive Survey of Health Insurance Providers in Connecticut," 1998.

11. NARAL-PA Foundation, A Special Report on Insurance Coverage of Reproductive Health Care in Pennsylvania (Philadelphia: NARAL-PA Foundation, June 1998), 6-7.

12. Deborah Senn, Washington State Insurance Commissioner, Reproductive Health Benefits Survey (Olympia: OIC, Sept. 1998), 20.

13. Illinois Women’s Health Coalition, "Does Managed Care Serve Women? Insurance Coverage of Reproductive Health Care in Illinois" (Oct. 1999), 4,6.

14. Women's Research and Education Institute (WREI), "Women's Health Care Costs and Experiences," Executive Summary (1994), 2-3.

15. The Auditor, State of Hawaii, "Study of Proposed Mandatory Health Insurance Coverage for Contraceptive Services," Feb. 1998, 11 (Report to the Governor and the Legislature of the State of Hawaii).

16. AGI, Uneven and Unequal, 4.

17. Kaiser Family Foundation, Kaiser Family Foundation National Survey on Insurance Coverage of Contraceptives, Questionnaire and Topline (Menlo Park: KKF, June 19, 1998).

18. Quinnipiac College Poll, "Connecticut Votes Back Birth Control Insurance 4-1, Quinnipiac College Poll Finds; Lieberman Gets Strong Approval From Republicans," Apr. 2, 1998 (press release).

19. Family Planning Advocates of NYS, "New York State Poll Results, New York Voters Support Contraceptive Coverage Equity, Legislature Should Pass Bill That Would Require Health Plans That Cover Prescriptions To Cover Prescription Birth Control," June 18, 1998 (press release).

20. Scripps Howard Texas Poll, June 1998 (on file with NARAL).

21. Stanley Henshaw, "Unintended Pregnancy in the United States," Family Planning Perspectives, vol. 30, no. 1 (Jan./Feb. 1998): 27.

22. James Trussell, et al., "The Economic Value of Contraception: A Comparison of 15 Methods," American Journal of Public Health, vol. 85, no. 4 (Apr 1995): 500.

23. Trussell, "The Economic Value," 497, 500.

24. Utah Office of Health Data Analysis, The Utah Health Data Committee 1998 Biennial report (Dec. 1998) <> (Feb. 8, 1999).

25. Jacqueline Darroch, Cost to Employer Health Plans of Covering Contraceptives, Summary, Methodology and Background (New York: AGI, June 1998), 1.

26. Rachel Benson Gold, "The Need for the Cost of Mandating Private Insurance Coverage of Contraception," The Alan Guttmacher Report on Public Policy (Aug. 1998): 5.

27. 144 Cong. Rec. S9194 (daily ed. July 19, 1998).

28. Suzanne Delbanco, et al., "Public Knowledge and Perceptions About Unplanned Pregnancy and Contraception in Three Countries," Family Planning Perspectives, vol. 29, no. 2 (Mar./Apr. 1997): 72.

29. Committee on Unintended Pregnancy, Best Intentions, 136; Elise F. Jones et al., Pregnancy, Contraception, and Family Planning Services in Industrialized Countries (New Haven, CT: Yale University Press, 1989), 218-19 (study by AGI).

30. Committee on Unintended Pregnancy, Best Intentions, 81.

31. The National Commission to Prevent Infant Mortality, Troubling Trends: The Health of America's Next Generation, (Washington, DC: National Commission to Prevent Infant Mortality, 1990), 25.

32. The NARAL Foundation/NARAL, Who Decides? A State-By-State Review of Abortion and Reproductive Rights, 1999, 8th Edition (Washington, D.C.: The NARAL Foundation/NARAL, 1999), xii; The NARAL Foundation/NARAL, Who Decides? A State-By-State Review of Abortion and Reproductive Rights, 2000, 9th Edition (Washington, D.C.: The NARAL Foundation/NARAL, 2000), vii.

33. In 2000, three states -- Delaware, Iowa, and Rhode Island -- enacted bills requiring insurance coverage of contraceptives. IA SF 2126 (2000), DE SB 87 (1999), RI SB 2367 (2000). In 1999, ten bills were enacted in 9 states: CA AB 39, CA SB 41, CT HB 5950, GA HB 374, HI SB 822, ME SB 389, NV AB 60, NH SB 175, NC SB 90, and VT HB 189. Maryland enacted a contraceptive equity law in 1998. Ch. 117, 1998 Md. Adv. Legis. Serv. 449 (Michie) (to be codified at §§15-826, 19-706). See also, The NARAL Foundation/NARAL, Who Decides? A State-By-State Review of Abortion and Reproductive Rights, 2000, 9th Edition (Washington, D.C.: The NARAL Foundation/NARAL, 2000).

34. Texas requires insurers that provide coverage for prescription drugs to provide coverage for oral contraceptives. 28 Tex. Admin. Code §§ 21.403, .404(3)(1999). Minnesota, New Jersey, and Wyoming require HMOs to cover voluntary family planning services. Minn. R. 4685.0100, subp. 5, Minn. R. 4685.0700, subp. 1 (1997 & Supp. 1999); N.J. Admin. Code tit. 8, § 38-5.4 (June 16, 1997); WCWR 044-000-013 §§ 3, 7(c)(ii)(B) (Feb. 1997). Three states require insurers to offer at least one plan in the individual and small group markets that provides coverage for contraception (ID, KY, NJ). Ky. Rev. Stat. Ann. § 304.17A-250 (Lexis Supp. 1998); Tit. 806 Admin. Regs. 17:180 (1999); N.J. Admin. Code tit. 11, § 20-3.1, App. Exh. A-F (April 19, 1999), N.J. Admin. Code tit. 11, § 21-3.1, App. Exh. F&G (Oct. 19, 1998); see also, The NARAL Foundation/ NARAL, Who Decides? A State-By-State Review of Abortion and Reproductive Rights, 1999, 9th Edition (Washington, D.C.: The NARAL Foundation/NARAL, 2000).

35. United States General Accounting Office, "Health Insurance Regulation: Wide Variation in States' Authority, Oversight and Resources," Dec. 1993, 5. (Report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives).

36. "Equity in Prescription Insurance and Contraceptive Coverage Act of 1997," H.R. 2174 (1997); "Equity in Prescription Insurance and Contraceptive Coverage Act of 1999," H.R. 2120 (1999), S. 1200 (1999).

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