If you listened to the scoffers of no-copay contraception coverage in the U.S., you’d think that preventing pregnancy was as simple as waltzing down to the local Walgreens and batting your eyelashes at the pharmacist. This demonstrates with almost total certainty that the scoffer is male, since the vast majority of women in the U.S. have used birth control and know the expense, fear, danger, and pure frustration of preventing pregnancy.
I can understand the scoffers’ point of view a little. As a kid, I also thought birth control was easy and simple. That lasted up till the first day I took a birth control pill. This blog post tells the anonymized stories of myself and women I know. Like Sandra Fluke, I’m talking about regular everyday women, not medical rarities or my friend’s ex-boyfriend’s sister-in-law. I hope this will help men understand the difficulty and expense of birth control, and perhaps even volunteer to help out with it in some way.
Let’s start with estrogen-based hormonal birth control and health. I know women who get life-threatening blood clots on estrogen birth control (if the clot gets lodged in a blood vessel, effects range from loss of a limb to death). Others have mood swings so bad that their partners threaten to break up with them and their boss calls them into their office to ask why they’re so mean and bitchy all of a sudden. Don’t laugh – losing your partner or your job is serious shit, and many women decide to risk pregnancy and an abortion rather than the certainty of being abandoned and broke. Another side effect is feeling like you’re going to barf, which usually goes away after a few weeks, but not for everyone. More side effects and health problems abound, but those are the ones I know about offhand.
Let’s talk access now. We’ll start with the easiest way to get the pill: go to your doctor and get a prescription and head down to the pharmacy. Oh wait, it’s illegal to write a prescription valid for more than a year, so you have to go back to your doctor once a year. Most doctors won’t write a prescription if you haven’t seen them in person in a year. Also, they want to do a full pelvic exam every year, and some doctors won’t refill unless you have the exam as a way to force you to get the exam. And I see why, it’s a pretty awful experience usually. Many medical professionals learned how to do pelvic exams on unconscious women pre-surgery (many of whom did not consent). As a result, they just kinda jam their hand in there and stab around, poking at things randomly, ignoring your winces and “Ow!” Then comes the Pap smear, which involves scraping flesh off your cervix, which hurts even more than it sounds like it would.
The first time this I ran out of my birth control prescription, my doctor was booked for weeks in advance but I got an appointment for a pelvic exam a couple of days before I ran out. Of course, if you’re in an HMO, your chances of getting an appointment in reasonable time are even lower. If you don’t have health insurance, well, hope your local women’s health clinic has an opening. Oh wait, you don’t have a local women’s health clinic? I wonder who’s been fighting to close them down?
On the day of my first appointment to get my birth control refilled, I got stuck in traffic and missed my appointment. They refused to let me in, at which point I broke down into tears and explained that I was almost out of birth control. They were nice and gave me a one month refill, just that one time. All of this was while I was a student and had a pretty flexible schedule. Many women can’t just run off in the middle of the day for a non-life-threatening medical visit. And if you miss 2 days of your birth control, you’re at risk of pregnancy for around a month.
When you have the prescription, refills are astonishingly hard. Most health insurance companies refuse to refill a prescription until it’s within a few days of running out. So you often have only 3 or 4 days to get your refill – god forbid you are busy or sick. Sometimes the pharmacy is out of your prescription. Sometimes your health insurance is having a random hiccup and suddenly thinks you don’t have coverage and it takes several days to fix. I no longer fill a prescription without coverage and submit the reimbursement (a hellish process that takes months) because often it turns out that you’re violating some subtle rule that the pharmacy won’t tell you about unless they can run it through the insurance company software, which it can only do if it thinks you’re covered, which it doesn’t. Then you’re stuck with some giant $70 or $200 bill or whatever. And there’s always a push to allow pharmacists to refuse to fill prescriptions that violate that personal beliefs – hope you don’t run into one of them!
Let’s talk cost. The fantasy of Planned Parenthood handing out birth control like candy isn’t true. While they often offer birth control at a discount to low-income women, I don’t personally know anyone who got free birth control from Planned Parenthood or anywhere else. There are individual programs in certain areas that allow qualified women to get free birth control, but you can be ineligible for all sorts of reasons even if you are broke, right now (a great time to get pregnant, we can all agree). Note also that Planned Parenthood clinics are few and often hard to get to, especially if you don’t have a car. Often the idiots promulgating this fantasy utopia are the very same people who want to defund Planned Parenthood and close down their clinics. Who’s going to pay for this free birth control? Maybe it will fall out of the sky like manna?
I’ve seen articles quoting low prices for generic birth control, like $8 a month. This works great if you are one of the women for whom the generics work. However, there are hundreds of different birth control pills for a reason: Women are different, and the same birth control that works for one woman can make another woman desperately sick, and simply not work for another one. They differ in dose, in timing, in the ratio of different hormones, and other ways. Some rely on progesterone instead of estrogen. I’ve switched birth control pills several times for these reasons as my body changed. I’ve never paid less than $30/month for my birth control, even when I lived on $6000 a year in college.
For women who can’t take estrogen birth control pills for health or sanity reasons, things get waaaay more complicated – and expensive. Let’s start with IUDs – hundreds or thousands of dollars, and I’ll spare you the graphic details of insertion and just say that your cervix is expressly designed to discourage you from this kind of activity (and they don’t use anesthesia, either). Nuvaring is a low-dose alternative to oral estrogen, but it’s not low-cost (my copay was the highest allowed, $45/month). Condoms, well, you do the math based on your own proclivities, but be sure to factor in use of Plan B emergency contraception several times a year (I paid $50) and if that fails (as it does), an abortion (several hundred dollars). I’ve never bought a diaphragm so I don’t know how much it costs, but it also requires factoring in an abortion a year. And don’t get me started about sterilization – most doctors won’t consider it for childless women or women under 30, and you can guess the cost, pain, and risk of death involved. We’re not talking $8 a month here for most women, no matter what.
Now let’s talk failure rates. You have to take the birth control pill every single day, within a few hours of the same time, to get that 98% or 99% effective rate. Big whoop, you may think. I take my blood pressure medicine every day. Usually. Actually, it’s pretty hard, even with those little day-of-the-week labels on the pills. I was always scared to death of being caught away from home overnight without my pills and occasionally did, due to car breakdowns or unreliable friends or snowstorms. Now I pop out 3 of my pills and carry them with me in a little pill box everywhere I go, even out to the grocery store. This works only because I have a version of birth control with the same dose all the time, which not all of them do. And I’ve never lost my pills in my luggage or something like that. If that happens, insurance won’t cover it and you’ll have to pay full price, if you’re even in a place where you can get your prescription filled.
Then there’s just plain forgetfulness or confusion. I put my pills on my bathroom sink where I have to see them everyday, but that’s not an option for everyone. I once got up so early that I took my birth control, and then an hour later was so tired that I thought it was the following day and took the second pill. That took weeks to get my cycle back to normal and safe from pregnancy. It only takes two days of missed pills before you’re having to convince your boyfriend to use a condom, and he’s all whiny and “Why do we have to, it’s almost no chance,” and of course just forgetting because you’re used to not needing them, and whoops, the condom came off and now you have to get Plan B within 72 hours, what, your pharmacy is closed on the weekends and your doctor isn’t answering your phone calls and you have to work a double shift on Monday? Sucks to be you. Good thing Plan B isn’t offered over the counter, that really makes America a better place to live!
Try taking a pill every single day, without fail for a year, and then tell me it’s easy. I have to take a lot of pills every day, so I put them in one of those pill cases with the day of the week, and I still screw it up all the time – at least once a month. Most medications are a little more forgiving of missed doses than birth control. Throw in international travel and whee, even more fun.
I’ve left a lot of the difficulties of contraception out of this post because it’s already too long. Suffice to say, birth control is hard to get, expensive, and error-prone. It’s also often painful, life-threatening (or life-saving), and humiliating. Health insurance companies want to encourage women to use birth control anyway, because women on birth control cost them less money than the reverse, on average. Insisting that they be allowed to provide no-copay contraception to their female clients regardless of their employers’ ideas strikes me as totally reasonable.