Insertion of devices at 90˚ to the umbilicus is not safe for overweight and obese women

Two key ACA contraceptive controversies
I read with interest this article written by Ms. DiVenere, MA, in the May issue of OBG Management. First let me say, I found it completely politically motivated and, as a result, misleading. I am board certified in both ObGyn and urogynecology and have been practicing for more than 20 years. I agree that contraception access is an essential component to women’s health; however, to this day, I have never witnessed women being denied access to reproductive services, including contraception. But access and complete coverage are two different concepts.

As a successful female surgeon, I find it insulting that my government feels that women cannot be responsible for their own reproductive health without their interference. I particularly take offense to the claim that if a nonprofit corporation does not offer contraceptive coverage based on religious grounds, the “outcome will have a profound affect on women’s health.” On what do you base this claim? Nonprofits like Hobby Lobby, which you used as an example, are not denying coverage of contraception to their employees. Most contraceptives will be covered under their plans. Only the abortifacients are excluded, which make up a small percentage of all contraceptive options.

Like Ms. DiVenere, I am a believer in the provider−patient relationship, but I am more fearful of my government interfering with that relationship (which I witness daily while providing care to my Medicare and Medicaid patients) than my employer (who ironically happens to be a catholic hospital system).

Renee Caputo, MD
Columbus, Ohio

Ms. DiVenere responds:
I very much appreciate Dr. Caputo’s points of view. She puts her finger on two key aspects of the contraceptive coverage controversy. First, are the contraceptives in question—levonorgestrel, ulipristal acetate, the copper IUD, and the levonorgestrel-releasing intrauterine system—abortifacients? Second, are out-of-pocket costs a barrier to contraceptive access?

The October 2014 issue of OBG Management contains an update on the Affordable Care Act (ACA).¹ In that update, I address the abortifacient issue based on ACOG’s medical and scientific findings. I note, among other things, that “although there is no scientific answer as to when life begins, ACOG and the medical community agree that pregnancy begins at implantation.”¹ This contrasts the argument put forth by Hobby Lobby attorneys that pregnancy begins at fertilization. If pregnancy begins at implantation, as ACOG and others contend, then the four contraceptives mentioned are not abortifacients.

The potential connection between access and “complete” coverage, I assume means “free” coverage, is also worthy of further exploration. In 2013, after the ACA mandate went into effect, 24 million more prescriptions for oral contraceptives (OCs) were filled with no copay than in 2012, resulting in $483 million in out-of-pocket savings for OCs. More important than any cost savings to individuals—and mindful that someone’s always picking up the tab—is the public health good of encouraging broader access to contraceptives, measured in fewer unplanned pregnancies, healthier pregnancies, and more.

It’s worth asking Dr. Caputo’s second question: Do deductibles and copays pose an access barrier and, if so, to what degree? Considerable testimony on this and other topics was offered to the Institute of Medicine during its consideration of which services should be included in the women’s preventive services package mandated to be offered without cost-sharing by plans offered on the exchanges. The Guttmacher Institute offered the following data:

Long-acting and permanent methods of birth control, including the IUD, implants, and sterilization, are most effective and cost-effective, but all can entail hundreds of dollars in up-front costs. Cost-sharing can pose a significant barrier to access to these most effective contraceptives.