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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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The Difference a Dollar Makes: Birth Control and the Presidential Race

I don’t have any children but am a firm believer that “it takes a village” to raise a child. As a public health nurse, I’ve done my best to talk with youth in my extended “family” about safer sex practices, particularly if I know their parents are not having these conversations.

Diana Mason, PhD, RN

So I was interested in what 1 college student in this extended family thought about the discussions about birth control during this presidential race. I’ll call her Jennifer. We have had many conversations about reproductive health, and when Jennifer has questions, from her menses to birth control, she often contacts me.

I recently asked Jennifer about the Obama administration’s regulation requiring employers, including most employers affiliated with religious organizations, to include birth control in their health insurance offerings to employees and their families. Jennifer told me that she doesn’t follow the news much—she works as many hours as she can to put herself through college—and was not aware of these issues. When I explained it to her, she said she supported the mandate.

Jennifer would fall within the 18- to 40-year-old category of women responding to a February survey by the Pew Research Center. On this survey, 53% of women in this age group who had heard about this issue said that religious organizations should be required to provide birth control coverage, compared with 40% who said they should be exempt from the mandate.

The Price of Prevention

Jennifer has been sexually active, with only 1 young man, since she was 16 years old. Although we’ve talked about the importance of using a barrier method of birth control along with her birth control pills, I was dismayed to learn that she had quit using condoms because “we’re not having sex with anyone else,” even though her boyfriend attends a different college and has broken off the relationship on several occasions. When I asked her why, she said, “Because they’re too expensive, and I’m barely making ends meet as it is.”

She said she paid about $1 per condom, which surprised me since New York City gives them away for free. I hadn’t looked at the price of condoms for decades, but a visit to a drug store in upstate New York left my mouth agape when I found the price of a popular brand was $17 for a box of 12. I later looked online and found condoms ranging from $0.30 to $2 each, depending on the brand.

Jennifer is typical of about half of US women who use birth control: she doesn’t use it correctly, like 40% of the women in the United States who have unplanned pregnancies. She has had trouble remembering to take her birth control pills. After we talked, she developed a routine for taking the pill and asked her physician for a generic brand that costs her only $14 a month.

She told me she had no health insurance because her father had lost his job and the family coverage through her mother’s job was too expensive. “I don’t have $50 a month for insurance…. [Catastrophic] insurance would be good, if it was cheap.” But that wouldn’t pay for birth control. Jennifer added that she would like to have health insurance but hopes she doesn’t need it. Her desire to have health insurance but being unable to afford it conflicts with Justice Anthony Scalia’s claim, during the Supreme Court hearings on the Affordable Care Act (ACA), that when young people “…think they have a substantial risk of incurring high medical bills, they’ll buy insurance like the rest of us.” Not if there’s no money to buy it. Jennifer’s monthly take-home pay averages $400.

The ACA and the Presidential Race

Under the ACA, Jennifer (and her parents) could qualify for subsidies to reduce the cost of purchasing health insurance once their state has an insurance exchange in place. In addition, women will have access to birth control and other preventive care without a co-pay—a recommendation from the Institute of Medicine.

Although Romney is clear about his intention to repeal the ACA and his position on abortion is summarized on his website, the site says nothing about his position on access to birth control. During the February uproar about Obama’s mandate that all employers, including employers affiliated with religious organizations, provide insurance that covers birth control, Romney framed the issue as one of religious freedom, without addressing women’s access to birth control. It didn’t play well with women. According to an April poll by the Pew Research Center, women continue to contribute to Obama’s lead over Romney by a margin of 13 percentage points: 53% for Obama and 40% for Romney. Obama fares well among people who think that birth control is an important issue, but this is more likely to be women (40%) than men (27%).

But Obama can’t take women’s votes for granted. His record on women’s reproductive issues is mixed. For example, the prochoice community decried Secretary Kathleen Sebelius’s override of the Food and Drug Administration recommendation to make Plan B (levonorgestrel) emergency contraception available over the counter to women of all ages. She claimed that there was not sufficient evidence that Plan B was safe for women younger than 17 years—a claim that was countered by others who noted that it’s safer than Tylenol (acetaminophen).

Planned Parenthood continues to be threatened with defunding at the federal and state levels, despite the fact that only 3% to 9% (depending on who’s counting) of its services are abortions. The vast majority of its services are preventive. Birth control composed 33.5% of its services in 2010; screening and treatment for sexually transmitted diseases (STDs) composed 38%. Romney has stated that he supports eliminating federal funding for Planned Parenthood, while Obama has pledged his continued support of the organization.

Why should people care about Planned Parenthood and access to birth control? Compared with the child of an intended pregnancy, unwanted pregnancies can have serious consequences, including poorer physical and mental health and cognitive functioning for the child; an increase in depression for the woman; and impaired family relationships. Sexually transmitted diseases are transmitted to an estimated 19 million people in the United States every year, with young people accounting for half of these new cases. What’s more, STDs cost the nation’s health care system $17 billion each year.

Jennifer says she doesn’t plan to vote for either candidate because she’s not sufficiently informed about them. I can’t blame her for not keeping up on the rhetorical war between the candidates and their parties. Still, I think about how much easier and safer her life would be if she had free access to birth control that would protect her from STDs, HIV, and pregnancy. Maybe I should send her some of those free NYC condoms.

About the author: Diana Mason, PhD, RN, is the Rudin Professor of Nursing and Co-Director of the Center for Health, Media, and Policy at the Hunter College, City University of New York, and President-elect of the American Academy of Nursing.
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