I still remember the first time a friend of mine reported back about getting an IUD after the passage of the Affordable Care Act. “I didn’t even pay a copay!” she said.
I didn’t believe her. It sounded too good to be true. And ever since the ACA made birth control unprecedentedly available, the GOP’s worked tirelessly to frame it that way: as an unreasonable gift for loose women, rather than what it is—an appropriate health care service covered by our insurance, which we pay for.
When it comes to the Affordable Care Act, birth control is one of many newly available benefits that the Trump administration is primed to interfere with over the next three years and nine months. Though Paul Ryan’s poorly-conceived American Health Care Act was so unpopular among Republicans that it had to be pulled from the House before even getting a vote, the Trump administration still has a number of options at their disposal to kill accessible health care through a thousand bureaucratic cuts rather than their promised Congressional overhaul.
Since November 9, I’ve frequently been asked what will happen to birth control coverage specifically, and the truth is, I don’t know. It’s hard to say. But there are hints of what the future holds. I reached out to a group of experts—attorneys with experience in health care policy, an ob/gyn, and reproductive rights advocates—to find out what some of the worst-case scenarios might be. In the process, I learned more than I thought possible about family planning funding, Medicaid, and Trump’s habit of hiring comically incompetent people. When it comes to protecting our health care, especially for women, here’s what might go wrong thanks to that potent mix—and what might give you hope.
One of the most disturbing potential rollbacks we could see from the Trump administration has to do with birth control, which the Affordable Care Act made newly accessible by requiring plans to cover it as preventive care, making birth control available without a copay. (That doesn’t mean birth control is free, by the way, because you’re still paying for your insurance.) When the Affordable Care Act categorized birth control as preventive medicine, it wasn’t revolutionary; it was practical. If you have a uterus, you know why: Birth control isn’t secondary to women’s health care. It’s often an essential part of it. According to the Guttmacher Institute, more than 99 percent of women aged 15 to 44 will use birth control to prevent pregnancy at some point in their lives. Though frequently maligned by the right for their contraceptive function, many birth control methods are also prescribed as medicine to treat a host of medical conditions, including painful periods, migraines, and endometriosis. Guttmacher reports that 14 percent of women who use the birth control pill alone take it for off-label reasons. Birth control is nothing short of critical. But before the ACA made it available without a copay, it could also be costly and out of reach.
“I can’t tell you how amazing it has been to see a woman, discuss all contraceptive options, and have her make a decision purely based on what seems right for her, without having to take cost into account. I have seen a huge uptick in IUD placements since the ACA.”—Dr. Carrie Miles, OB/GYN
Oregon obstetrician/gynecologist Dr. Carrie Miles has some firsthand experience with this.
“It was not at all unusual before the ACA that I’d see a woman who wanted an IUD, but her insurance either didn’t cover it at all or only covered part of the cost, and the remainder was prohibitively expensive, or at least expensive enough to deter her from easily choosing it,” she says. “I can’t tell you how amazing it has been to see a woman, discuss all contraceptive options, and have her make a decision purely based on what seems right for her, without having to take cost into account. I have seen a huge uptick in IUD placements since the ACA.”
Miles is a physician at Bridgeview Women’s Health, a private practice in Northwest Portland. She’s also an outspoken supporter of reproductive rights. And as gratified as she is to see improved access to birth control for her patients, she’s also worried. Because the mandate that made birth control available without a copay could be on the chopping block.
The ACA may still be the law of the land, but the Trump administration has the ability to reshuffle what it does and doesn’t categorize as an essential health benefit. The lawyers I spoke to expressed concern about parts of the law that are categorized as “guidance,” because it’s easier to amend these individual pieces of the ACA than to overhaul the law comprehensively. And the official in charge of what happens to the birth control mandate is Secretary of Health and Human Services Tom Price, whose complete lack of knowledge about women’s health care is best demonstrated by his response to inquiries about the birth control mandate, when he glibly claimed that “not one” woman had trouble paying for her birth control. (And surprise! He’s also anti-choice!)
If birth control is no longer categorized as an essential health benefit, we could go back to the bad old days of paying through the nose for it. Even in a relatively birth control-friendly state like Oregon, where you can buy birth control pills over the counter and receive a one-year supply at a time, Price could be make sure many women lose their affordable access to birth control. That’s what Miles and other advocates are worried about.
Katherine McGuinness, board president of the Oregon abortion fund Network for Reproductive Options, says she’s especially concerned about what might happen to abortion and birth control access for women who don’t qualify for Medicaid coverage through the state, but who also don’t make enough money to afford comprehensive insurance plans through the Affordable Care Act—or to pay for the costs of abortion or birth control out of pocket. For “people who are already stretching to pay for insurance,” she says, losing the birth control benefit could mean losing access.
And Miles brings up another complicating factor. “If there is no longer federal regulation requiring contraceptive coverage in full, then it goes to the states,” she says. While that might not be a problem in a blue state like Oregon, “Many of our patients get their insurance from outside the state. We see a lot of women whose insurance is based in conservative places like Texas and South Carolina.”
Miles also points out that around 50 percent of employees in Oregon work for companies that self-insure, and these businesses aren’t subject to the state’s insurance laws.
“It would be easy for the employer to decide that they want to go back to requiring employees to share a portion of the cost for contraception, or they could decide they don’t believe in providing contraceptive coverage,” she says. “I’d like to think these businesses would do the right thing and continue the current coverage because (A) it’s popular and (B) it’s cost-saving—but the skeptic in me is not optimistic.”
Tom Price undermining the ACA’s birth control mandate is one worst-case scenario. But another way health care protections could be weakened is through an obscure provision called the Congressional Review Act, which allows Congress to overturn rules passed during the final days of an outgoing administration.
We’ve already seen what this looks like in action. At the end of March, Senate Republicans used the Congressional Review Act to roll back a rule set by the Obama administration that prohibits states from selectively blocking federal family planning funding from organizations that provide abortions. When the Republicans yell about defunding Planned Parenthood, this is what they mean. They aren’t talking about federal funding for abortion, which has been outlawed with few exceptions since Congress passed the Hyde Amendment in 1976. They’re talking about Title X funding, which pays for services like birth control, cervical and breast cancer screenings, basic fertility services, pregnancy care, and screenings and treatments for sexually transmitted infections. None of these are abortion. On March 30, Vice President Mike Pence and ailing Republican Senator Johnny Isakson were dramatically called into the Senate to cast tie-breaking votes in favor of letting states pull funding for these basic health care services. On April 13, Trump signed off on it in private.
Because they’re more likely to receive their health care through the government, low-income women and women of color will be disproportionately impacted by this loss of funding. The fallout for an organization like Planned Parenthood could be huge.
“Planned Parenthood health centers provide care for approximately 1.5 million patients through Title X, roughly one-third of the more than four million people served by the program nationwide,” said representatives from Planned Parenthood Advocates of Oregon in a statement after the bill was passed. “The Title X program is especially important for women of color, who are disproportionately unable to access basic, preventive health care because of economic disadvantages in access to education, housing, and employer-sponsored health insurance.”
This is only one rule we’ve seen overturned through the Congressional Review Act. According to a memo released by the Congressional Research Service last November, there are roughly 50 Obama administration rules categorized as “major” that could be summarily reversed. Of those, at least 15 are related to health care.
So the Trump administration is a danger to women, in more ways than one. What else is new? And who else is fucked? The current administration’s capacity to do harm by weakening our health care runs deep, and it starts with Trump’s horrible associates.
Let’s begin with Roger Severino, Trump’s appointee to lead the Health and Human Services Office of Civil Rights. Severino is notoriously bigoted towards the LGBTQ community, and heading up the Office of Civil Rights puts him in a uniquely terrible position to complicate health care for transgender patients. Next up in Trump’s motley crew of absurd appointments is Seema Verma, whose claim to fame is tacking on a work requirement for Medicaid recipients in Indiana. Guess what she’s in charge of? Medicaid.
If you’re sensing a theme, you’re not crazy: The hallmark of Trump’s early presidency seems to be assigning offices to people whose records suggest they’ll undermine their own jobs. It’s infuriating and yet tragicomically appropriate, coming from a person who ran for president and now appears to have more interest in eating chocolate cake and playing golf.
But as counterintuitive as it may seem, this is also where the good news comes in. (I promised! Thanks for sticking around.) If there’s anything we can pin our hopes on at this odd juncture for health care and civil rights for marginalized communities, it’s that the Trump administration and the GOP will continue to be stymied by their own profound ineptitude. After all, despite their radiant smiles in the ensuing press conference, it wasn’t the Democrats who killed the AHCA. It was the GOP. Thanks to a beautiful convergence of factors we couldn’t possibly have foreseen—unexpected, obstinate opposition from the Freedom Caucus, Trump’s own misunderstanding of Congressional protocols, and Paul Ryan’s inability to craft any kind of appropriate replacement legislation for the ACA—the AHCA died before it even made it to a vote. Under the Obama administration, Republicans clung fiercely to their obstructionism. Now that they’re in power, they don’t know how to wield it. This, coupled with an incompetent, dysfunctional leaky ship of a White House, has ensured that, at least for now, the GOP’s obstructionist spirit has outlived its usefulness. That’s good news for Democrats.
Just last week, the Trump administration began lobbying House Republicans to run an amended version of their awful health care bill. Yet again, the timing was arbitrary—a desperate attempt to gain legitimacy by trying to pass this legislation (or, really,
any legislation) before Trump’s first 100 days in office are over. It’s not unusual for politicians to do inadvisable things for purely optical reasons. That happens all the time. But what’s interesting when it comes to this shoddy attempt is that the new health care bill will coincide with a truly legitimate priority for the House: passing the budget. In other words, the timing couldn’t be worse. Under these conditions, the bill will likely face opposition from Republicans and Democrats alike, which is exactly what happened last time.
Incompetence may be the thing that saves us.