States Explore Bills to Address Contraceptive Access in 2018

March 15, 2018|2:59 p.m.| ASTHO Staff

Healthy People 2020 sets out national goals and science-based objectives to improve the lives and wellbeing of all Americans. One of the goals is to increase the proportion of women at risk of an unintended pregnancy and their partners who use contraception. State policymakers can leverage laws, regulations, and other policies to promote access to contraception in support of that goal.

ASTHO is currently tracking over 130 bills addressing access to contraception. Key legislative trends include expanding the role of pharmacists to provide self-administered forms of contraceptives, ensuing contraceptives are covered by health plans, as well as promoting contraceptive education, training, and resources for key populations.  

Expanding Access to Self-Administered Hormonal Contraceptives by Pharmacists

Currently, laws or regulations in California, Colorado, Washington, D.C., Hawaii, New Jersey, Maryland, New Mexico, Oregon, and Washington allow pharmacists to provide certain forms of contraceptives. Legislatures in 10 additional jurisdictions are considering the issue this year.

Policy considerations include:

  • How to grant authority to pharmacists to provide contraceptives (i.e., expanded scope of practice or standing orders and protocols).
  • The specific education, training, and reporting requirements pharmacists must comply with to provide contraceptives.
  • Whether women must provide evidence of an initial prescription before obtaining contraceptives from a pharmacist.
  • The specific form(s) of contraceptives are pharmacists authorized to provide.
  • Whether contraceptive access will be limited by age (i.e., pharmacists can only provide contraceptives to women over 18).

Proponents stress that pharmacists are one of the most accessible healthcare providers, with locations in rural communities and often operate with extended hours. Opponents raise concerns that bypassing primary care providers for contraceptives may mean that women will skip or delay other preventive care.

Pharmacists may also be resistant to make this service available. In California, researchers found that only 11 percent of pharmacies provided contraceptives one year after its law went into effect. Reimbursement issues present one barrier since health insurance may not cover the cost of a pharmacist consultation. Several of the bills considered in 2018 incorporate coverage requirements. For example, a bill in Iowa (SSB 3169) adds language to require insurance companies to provide payment for “oral hormonal contraceptives which are prescribed by a practitioner authorized to prescribe drugs in this state, including pharmacists.” Additional barriers that may prevent pharmacists from providing contraceptives include concerns over liability, ensuring adequate staff to provide the services, and low patient demand due to a lack of public awareness of the new laws.

Improving Coverage for Contraceptives

Access to contraception is considered an essential health benefit that must be covered without cost-sharing under federal law. At least 21 jurisdictions have bills this session to also incorporate contraceptive coverage benefits under state law. Typically, these bills require coverage for at least one form of contraceptive within each FDA-approved class without deductibles, coinsurance, co-payments or other cost-sharing mechanisms.

Other coverage and reimbursement strategies states are considering include unbundling the immediate post-partum provision of long-acting reversible contraception (LARC) from Medicaid payments for births (e.g., Utah SB 12), increasing income eligibility limits for state family planning programs (e.g. Maryland HB 994, raising income eligibility to 250 percent of the federal poverty level), and requiring insurance coverage for a 12-month supply of contraceptives (e.g., Idaho S 1281). In addition, jurisdictions can leverage policies to assure reproductive health benefits can be accessed confidentially and encourage people to use them. For example, in Massachusetts, the legislature passed a bill (SB 2296) to prohibit insurance companies from including “sensitive health care services in a common summary of payments.” The bill specifically requires the division of insurance to consult with experts in “reproductive and sexual health” to define sensitive healthcare services.

Promoting Contraceptive Education and Outreach

States are also considering policies to increase awareness of contraceptive resources focusing on key populations, including medical providers and women with substance use disorders. A New York bill would require hospitals that offer “medical resident training in obstetrics, gynecology, internal medicine, or women’s health” to “provide structured didactic and clinical training experiences in all forms of family planning.” Routine contraceptive counselling empowers women to make decisions about their reproductive health, so it is essential to equip healthcare providers with the tools and training to effectively deliver that counselling.

Several states also have bills that address contraceptive access for women with substance use disorders (SUD) or women being prescribed opioids. Women with SUD have higher rates of unintended pregnancies than other groups and substance use during pregnancy increases the risk of poor health outcomes for women and infants. Increased incidence of neonatal abstinence syndrome presents a particular concern with the opioid epidemic. Bills in Tennessee would require a healthcare provider prescribing more than five days of opioids to a woman of childbearing years to counsel the patient about the risk of neonatal abstinence syndrome and assist her obtain voluntary LARC or other methods of contraception. Additionally, a bill in Alaska would establish a study to evaluate the effectiveness of providing voluntary LARC to women with SUD to prevent neonatal abstinence and fetal alcohol syndrome. The bills in both states stress the ethical requirement that LARC services be made available voluntarily.

Improving access to contraception to reduce the risk of unintended pregnancy is vital intervention to improve the lives and wellbeing of women, children, and families. ASTHO will continue to monitor these and other bills as state policymakers continue to explore the issues.