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The politics of the pill 

When Jane Miller handed in her prescription for birth-control pills several weeks ago, she assumed they would cost the same as other medications she'd bought under her parents' Blue Cross/Blue Shield policy. Instead of paying $10, though, she had to hand over $35. Feeling stiffed, Miller, a University of Central Florida student who asked that her real name not be used, called her mom to double-check Blue Cross' benefits. Sure enough, contraceptives were absent from the list of medications the company paid for. "My mom checked her information and it was like, wow, Blue Cross doesn't cover them," she says.

Miller, though, had a happy ending in her search for affordable birth control. She discovered her campus Women's Health Center, where a month's supply of birth-control pills costs $10.

Many women haven't been as lucky. Approximately half of the 6 million babies conceived in 1996 resulted from unintended pregnancies, according to a Family Planning Perspectives survey. Family-planning experts, citing comparisons with European countries, think the number should be much lower. And they think insurance companies should help to prevent pregnancies by ensuring cheap contraceptives.

"I have no idea why insurance companies don't cover them," says Paul Gluck, a Miami obstetrician. "They'll cover sterilization."

By October, this could change. Two bills in the Florida Legislature would require insurance carriers to cover oral contraceptives. The argument implicit in the bills is that insurance companies -- as well as the public -- will benefit once the price of contraceptives are weighed against the price of delivering babies. "It costs $360 per year to pay for a woman's birth-control prescription," says Steven Effman, a House Democrat from Sunrise who sponsored one of the bills. "The cost of delivering a baby is $5,500 -- and that's without any complications."

The bills are identical to two bills that died in the Legislature last year, one by Effman and another by Patsy Kurth. Effman implies that he has a different strategy this year for pushing past the insurance lobby. "There's an old saying: If at first you don't succeed ...," he says.

Blame Viagra, if you like, for Effman and Kurth's drive for cheap birth control on behalf of the state's 3 million child-bearing women, approximately 75 percent of whom are fortunate enough to have insurance protection. Before the spring of 1998, when Viagra was introduced, no state had passed a law requiring insurers to cover contraceptives. Once Viagra became available, insurers scrambled to voluntarily cover the erection-friendly drug.

Women advocates naturally were sensitive to the attention Viagra received. They began pushing for coverage of contraceptives, because studies show that while 97 percent of insurers will cover drug prescriptions, only 15 percent cover all five reversible contraceptive methods (the pill, Norplant, diaphragm, Depo-Provera injections and IUDs). The advocates' success varied: 10 states today have laws forcing insurers to cover oral contraceptives. A federal bill never made it out of committee.

Arguments in favor of the pill rely mainly on statistical evidence. Birth control saves between $4 and $14 in health costs for every dollar spent, say advocates. An employer, meanwhile, can expect to pay an additional $1.43 per employee per month for contraceptive coverage.

What doesn't make sense to many health experts is that in addition to sterilization, many insurers will pay for abortions (according to the Sexual Information and Education Council of the United States) but not the pill, even though a small percentage of women are prescribed synthetic progestin (the hormone in the pill) for nonreproductive medical conditions.

"My 16-year-old daughter is on the pill," says Gluck, vice chairman of Florida's chapter of the American College of Obstetricians and Gynecolo-gists. "She's not sexually active. At least, I don't think she is. She's had very, very bad menstrual pain. For that, the pill is excellent." Physicians also prescribe the pill for women with irregular periods or who have symptoms of early menopause.

Not content to argue strictly from a public-safety standpoint, many women advocates also point out the unfairness of covering Viagra but not the pill.

In a 1998 op-ed piece for the Chicago Tribune, Janet Benshoof of the Center for Reproductive Law and Policy summed up the inherent bias: "What it really comes down to is this: There are strong stereotypes about women that are behind this discrimination. Men are meant to have erections and sexual pleasure. Hence, fund Viagra. Women are designed to get pregnant, become mothers, and not be sexual. Hence don't fund 'unnatural' contraception or abortion."

Insurers, meanwhile, continue to talk up the tragic consequences of forcing them to cover birth control. Insurance companies look at the 51 requirements -- called benefit mandates -- signed into Florida law, covering everything from acupuncture to massages, and wonder how much more they can take. The state has the highest number of benefit mandates in the nation.

Mandates "are like wildfires out of control," says Jodi Chase of Associated Industries, a lobbying group that was successful in exempting its clients, 7,000 small businesses, from Effman's bill last year.

There's no doubt that in many instances mandates do create a run on health services. In a recently released report from an Insurance Committee study commission, one HMO reported that the number of its dermatology visits increased 85 percent in a three-year span even though the HMO's patient enrollment increased only 29 percent during the same time period. The reason? Florida enacted a law requiring direct access to dermatologists.

A problem is that nobody is sure about how mandates affect the number of uninsured patients.

A 1996 report from the U.S. General Accounting Office said mandates add between 5 and 22 percent to the cost of insurance, depending upon the region. And the higher cost means an increase in the number of uninsured residents -- but only to a certain extent. States with fewer than 10 mandates have the lowest average uninsured population (13.4 percent). As the number of mandates increases, from 20 to 30, the number of uninsured inches up from 15.6 percent of the population to 16.8 percent. But as a state (like Florida) moves into the top bracket above 40 mandates, the number of uninsured goes back to 16.3 percent.

What that means for the state's health industry is that legislators would like more research done before passing more mandates. Researchers who put together the report admit their study could have more of an impact if insurance companies would have done cost analyses on the mandates Florida has passed. "We were astonished at how little information was out there," says Stan Bainter, who chairs the House Insurance Committee.

Don't look for the issue of insurance coverage for contraceptives to go away any time soon. More than 70 percent of Americans like the idea, even if it means slightly higher insurance premiums. Most of them, like Jane Miller, have some advice for insurance companies worried about their rising costs. "Take Viagra off the list, then," she says.


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