Reproductive Equity Now Issues Public Comment to 3 Agencies
TARGETED NEWS SERVICE (founded 2004) features non-partisan 'edited journalism' news briefs and information for news organizations, public policy groups and individuals; as well as 'gathered' public policy information, including news releases, reports, speeches. For more information contact
The comment, on Docket No. EBSA-2023-0013-0001, was sent to HHS Secretary
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We are writing in response to the Request for Information (RFI) 120-ZA31 issued by your agencies regarding insurance coverage of over-the-counter (OTC) preventative services and items. Reproductive Equity Now strongly supports insurance coverage without a prescription and without cost-sharing of all OTC preventative products and services outlined in the
Aligned with our commitmentto health equity and reproductive justice, we urge the Administration to require insurance coverage for OTC contraception, folic acid during pregnancy, and breastfeeding supplies without a prescription requirement and without cost sharing. This proposal is an opportunity to address the systemic inequities present in our health care system that create barriers to access, particularly for BIPOC communities, immigrants, young people, LGBTQ+ people, rural residents, and people with disabilities. As private insurers and Medicaid generally require a prescription to cover OTC products, making preventative services available without a prescription will remove a barrier to care and help increase access. Additionally, requiring insurance coverage of the proposed OTC preventative products and services with no cost-sharing will be key to ensuring meaningful access, without cost barriers, to these products for consumers./1 Since 2020, Reproductive Equity Now has dedicated significant attention towards implementing several contraceptive access statutes in
The right to reproductive health care, including care for contraception, pregnancy, delivery, abortion, and miscarriage care, is not a real right unless every individual can safely access that care with autonomy and dignity. This includes meaningful access to contraception, folic acid to improve pregnancy outcomes, and post-pregnancy care such as breastfeeding supplies. As twenty-one states have moved to ban or severely restrict access to abortion in the wake of Dobbs v.
I. Oral contraception prescription requirements create barriers to access
The
1
2 See Tracking the States Where Abortion is Now Banned,
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...nation by removing the barrier to obtaining a prescription at a time when states are moving to restrict access to reproductive health care such as abortion. As the
Making oral contraception available over the counter without a prescription will address barriers present due to systemic discrimination in health care. Women, especially women of color, are more likely to suffer discrimination, abuse, and stigma in health care which may impact their access to care available with only a prescription. For example, thirty-three percent of Indigenous women, twenty-five percent of Latinx women, and twenty-three percent of Black women report mistreatment in health care at large./8 In terms of access to contraception, women report similar systemic barriers./9 For instance, a recent study found that forty-five percent of respondents...
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4
6
7
8
9 Id.
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...reported experiencing at least one barrier to accessing contraception in the past year./10 Those who were younger, identified as BIPOC, or who had lower levels of education were more likely to have experienced a challenge to access contraception./11 Systemic discrimination related to sexual orientation and gender identity also poses a barrier to contraception access. Research indicates that lesbian and bisexual women have significantly lower odds of receiving contraception compared with heterosexual women./12 Similarly, transgender individuals, particularly transgender men, face barriers to contraceptive care as they may anticipate being misgendered by clinicians, fear having their transgender status revealed, or feel uncomfortable and potentially unsafe in a clinical setting populated with primarily cisgender women patients./13 Aligned with these systemic barriers, research indicates that trans masculine people are prescribed fewer oral contraceptives than cisgender women./14 The need for a prescription has the potential to exacerbate this stigma, increase discrimination and mistreatment experienced in the health care system, and cause people to not seek care involving a prescription.
Expanding access to contraception without a prescription offers an opportunity to connect young people to care who may face difficulty navigating the health care system. According to a 2022 national study conducted by Advocates for Youth, barriers to accessing a prescription can be daunting, particularly for low-income and other marginalized teens: fifty-five percent reported facing at least one barrier to accessing prescription birth control pills that prevented them from obtaining it, thirty-six percent of respondents reported they lacked the time to schedule or attend an appointment with a clinician to obtain a birth control prescription, and nearly one-third of all respondents indicated that they did not have a regular health care provider./15 Notably, of the respondents who were prevented from accessing prescription birth control pills, fifty-eight percent had pregnancy scares and twenty percent had unintended pregnancies./16
Requiring coverage for OTC oral contraception without a prescription is an opportunity to remove barriers for rural people and those who live in contraceptive deserts./17 For example, nineteen...
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11 Id.
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13 A. Francis et al., Contraceptive challenges and the transgender individual, 4 WOMEN'S MIDLIFE HEALTH J. 12 (2018), https://womensmidlifehealthjournal.biomedcentral.com/articles/10.1186/s40695-018-0042-1#citeas.
14
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16 Id.
17 Contraceptive deserts are a type of access desert, defined by Power to Decide as "counties where the number of health centers offering the full range of methods is not enough to meet the needs of the county's number of women eligible for publicly funded contraception, defined as at least one health center for every 1,000 women in need of publicly funded contraception." Contraceptive Deserts, POWER TO DECIDE , https://powertodecide.org/what-we-do/contraceptive-deserts (last visited
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...million women in
II. Cost creates barriers to access to contraception
Out-of-pocket cost is a primary barrier to accessing health care services in general, including contraception. As previously noted, while prescription contraception is required to be covered without cost-sharing under the ACA, the current federal policy does not apply to OTC contraception. As OTC oral contraception becomes available, it is crucial not to shift the cost burden from health care systems and insurance to individuals. No-cost insurance coverage of over-the-counter oral contraceptives removes cost barriers, especially for groups that face higher access barriers such as young people and people with low incomes. Several states have enacted laws requiring state-regulated private health plans to cover certain OTC contraception (such as emergency contraception and condoms) without a prescription and without patient-cost sharing, though these important strides do not apply to the nearly two-thirds of workers with employer-sponsored insurance that is not subject to these mandates./19 Several states have also moved to use state-only funds to provide coverage for certain OTC contraceptives without a prescription for Medicaid beneficiaries./20 Requiring no cost sharing for OTC contraceptives, similar to the ACA requirements, will address this patchwork coverage for patients across the nation by removing the significant barrier of cost. A uniform national approach will not only remove the cost barrier for people in all states, but will also improve implementation by avoiding patchwork policies across states, making it easier to educate consumers, providers, pharmacies, and other stakeholders about the increased coverage.
18 Id.
19 As of
20 State Medicaid Insurance Coverage Requirements for OTC Contraception Without a Prescription, KFF (last updated
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While some states have moved to cover OTC contraceptives without cost-sharing, research indicates that cost concerns are a persistent barrier to patient access. A recent study found that a large population of women would likely use OTC oral contraception with no or low out-of-pocket costs./21 This study concluded that a low retail price and insurance coverage are crucial to providing equitable access to OTC oral contraceptives for low-income populations which would reduce barriers to contraceptive access and potentially decrease unintended pregnancy./22 Similarly, another study assessing interest in the continued use of OTC contraceptives found cost barriers including participants being unable or unwilling to pay out of pocket for an OTC oral contraception compared to prescription oral contraception (even if they wanted to continue with the OTC contraceptives)./23
III. Access barriers to folic acid during pregnancy and breastfeeding supplies
While folic acid supplements and breastfeeding supplies are available over the counter without a prescription, under current federal guidance, a prescription is required to obtain insurance coverage of these OTC items. Patients face similar barriers in obtaining a prescription for folic acid or breastfeeding supplies as patients face in obtaining a contraception prescription, including systemic discrimination and lack of access to a provider discussed previously.
The benefits of folic acid during pregnancy are well-documented/24 and folic acid is both covered by insurance with a prescription after the enactment of the ACA and widely available over the counter without a prescription. Alarmingly, despite the implementation of the ACA which provided insurance coverage for prescription folic acid, significant racial and ethnic disparities exist between Black and Hispanic women and non-Hispanic white women./25 Research indicates that lack of access is a major contributing factor to racial disparities. Chief among access barriers is out-of-pocket costs for OTC folic acid if patients are unable to obtain a prescription from their provider./26
Access to breastfeeding supplies with no cost sharing is one of many barriers to successful breastfeeding. While the benefits of breastfeeding are well-documented in reducing many different health risks for mothers and children, many barriers remain including lack of knowledge,...
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22 Id.
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24 As noted in the
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26 Id.
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...social norms, poor social or familial support, employment and childcare barriers, and lactation problems./27 Significant racial and ethnic disparities exist in
IV. Implementation Considerations
Based on our experience of implementation across
1. Issue guidance requiring insurers to cover the OTC contraception, folic acid, and breastfeeding supplies without age restrictions to ensure young people have access without parental consent. This guidance should include specific coding information to ensure that pharmacists and insurers can communicate clearly about insurance coverage of OTC contraception, folic acid, and breastfeeding supplies.
2. Promulgate regulations that include mandatory reporting by providers, pharmacists, and insurers on the number of OTC services and items accessed to track consumer use of the newly covered products and provide data for spotting any trends or issues in OTC coverage without prescription and without cost sharing.
3. Administrative guidance to stakeholders such as pharmacists, trade associations, and insurers will be critical for successful implementation. We recommend that pharmacists in particular receive guidance and training on processing OTC claims.
27 OFFICE OF THE
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29 AM. COLL. OF OBSTETRICIANS & GYNECOLOGISTS, COMM. ON GYNECOLOGIC PRACTICE OP., COMMITTEE OPINION: BARRIERS TO BREASTFEEDING: SUPPORTING INITIATION AND CONTINUATION OF BREASTFEEDING (
30 An Act Relative to Advancing Contraceptive Coverage and Economic Security in our State ("ACCESS"), signed into law in
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4. Issue guidance to protect confidential health care information in health insurance documentation for dependents on an insurance policy, such as explanation of services and summary of payment forms. Without protecting information related to reproductive health care, young patients or patients experiencing domestic violence may opt not to use the insurance coverage if they fear a parent or partner will find the service listed in an insurance summary of payment or explanation of services.
5. Allocate funding for a public education campaign to educate patients about the availability of insurance coverage of preventive services without a prescription and without cost-sharing. Public education is key to ensuring meaningful access to preventative services and products included in the
6. Include requirements for coverage at the point of sale at all pharmacies to ensure no out-of-pocket costs are incurred by consumers. If consumers are alternatively required to pay for the OTC product at the point of purchase and later submit a claim for insurance reimbursement, barriers to access will remain. For instance, consumers may lack the funds to pay for products up-front and therefore still lack meaningful access to preventive supplies, or consumers may not receive reimbursement for out-of-pocket costs if they do not properly submit a reimbursement claim.
The work to advance reproductive health equity is broad and we thank you for the opportunity to provide information to expand access to reproductive-related care without a prescription and without cost sharing.
Sincerely,
President
Reproductive Equity Now
31
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Original text here: https://downloads.regulations.gov/EBSA-2023-0013-0280/attachment_1.pdf
TARGETED NEWS SERVICE (founded 2004) features non-partisan 'edited journalism' news briefs and information for news organizations, public policy groups and individuals; as well as 'gathered' public policy information, including news releases, reports, speeches. For more information contact
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