This week I spoke with Beth Sundstrom and Andrea DeMaria, Co-Directors of the Women’s Health Research Team at the College of Charleston, about why the pill is still our go-to birth control choice when we have long acting reversible contraception methods like the IUD and the implant available for women. You can listen to the entire episode above, but researching the topic got me thinking about the cost of contraception and access to birth control.
Whenever we think “access to contraception” we tend to think in dollars. And that seems entirely reasonable because, if you’ve ever had to pay for the stuff, you know it can be really expensive. Even when it’s relatively cheap (like here in Canada) it still adds up fast, especially if you don’t have prescription coverage or insurance. So let’s do a quick “back of the napkin” estimate. We’ll use the pill because it’s still the most popular form of contraception other than the condom, with four of every five sexually active woman having used it at some point.
Here in Canada, the pill will usually run you between $16 CAD – $25 CAD per month, which per year works out to be $192 CAD – $300 CAD. That’s the baseline “out of pocket” cost if you don’t have prescription coverage through your job, parents, or university, and assuming you never want to skip a period. (Because probably the ability to skip your period should be considered a “luxury”?)
I tried to look up the cost of the pill in the US, but threw up my hands in dismay. The price of the pill is all over the place: it seems to range from $9 US – $50 US depending on what state you’re in, where you buy it, and what brand it is. That runs anywhere from $108 US – $600 US per year.
So let’s assume a person in possession of a uterus who wants said uterus to remain vacant starts taking the pill at 18 and stays on it until she turns 25. That’s 7 years paying for the pill, which works out to $1,344 CAD – $2,100 CAD if you live in Canada, and somewhere in the vast chasm between $756 US – $4,200 US if you live in the USA.
Lets say you’re off the pill for a few years while you take advantage of the human-making factory that is your uterus. You have your first kid at 27 and your second at 30, and are off birth control that entire time. On your 31sth birthday you take your uterus off the baby-making market and go back on the pill. The NIH website says the average age a woman will have her last period is 51, so let’s run with that number. For the sake of this exercise, let’s say you stay on the pill continuously until you hit menopause, another 20 years. In Canada that’s another $3,840 CAD – $6,000 CAD to add to your contraception tab, while in the USA those years will run you anywhere from $2,160 US – $12,000 US.
Your total for 27 years of (hopefully) baby-free living comes to $5,184 CAD – $8,100 CAD in Canada, and $2,916 US – $16,200 US in the USA.
This is, of course, assuming you don’t have prescription benefits or health insurance that covers the pill. But if we’re talking questions of access, we should probably assume you don’t have coverage. In the USA, even with Affordable Care Act, there are still 33 million people living without health insurance, which is 10.4% of the population. In Canada it’s estimated one third of working Canadians don’t have employer-provided prescription coverage, and that 10% of us don’t take a prescription we’re supposed to because of the cost.
Also, it’s important to remember you’re not going to get 27 years of pill refills up front. You’re probably going to have to go in to see your doctor once per year. If you’re in Canada those visits are covered by our socialized healthcare system and don’t affect your contraception tab. If you’re in the US and are without insurance (and don’t live in Oregon or California where you can get it over the counter) you may have to pay for every one of those doctors visits, to the tune of anywhere from $35 US – $200 US per visit. That works out to an additional $918 US – $5,400 US to cover birth-control related doctors visits over your lifetime. Your new uninsured grand total for contraception use over 27 years in the US comes to between $3,834 US – $21,600 US. Yikes.
If you don’t like my math, here’s a write up with some math done by the Centre for American Progress, which also includes estimates for some of the other contraceptive options.
It’s also important to remember that access isn’t just about being able to pay for it. Obviously, being able to cover the cost – or have the cost covered for you – is important, but it’s far from the only block to access for at-risk groups. How difficult a contraception method is to obtain isn’t just about what it costs in dollars: it’s also about what it costs in time, effort, energy, and social capital.
In 2014 the Kaiser Family Foundation released a survey of nearly 3,000 women in the US. They looked at cost barriers, but they also looked at another major hurdle for many people trying to access health care: time and logistics.
From the report:
Many women report they can’t find the time (23%) or take time off work (19%) to get their care. Childcare (15%) and transportation problems (9%) also prevent some women from getting to care, and are more frequently reported among low-income women (19% and 18%, respectively). One-quarter of all women, regardless of income, reported that lack of time to go to the doctor was a reason they went without care. While the ACA and other reforms have the potential to help offset coverage gaps and assist with the burdens of costs, the survey finds that factors such as work place flexibility, sick leave, and child care also have implications for women’s access to care.
From the Kaiser Family Foundation report “Women and Health Care in the Early Years of the Affordable Care Act”
Doctors offices and clinics are often open during 9 – 5 hours, which just happens to be the same time a lot of people are themselves at work. While it is sometimes possible to get a lunch hour, evening or weekend appointment, let’s face it: most doctors would prefer you show up between 9 – 5, Monday to Friday. If your job doesn’t give you paid sick time, you may not be able to get – or be able to afford – the time off. And you never know exactly how long you’re going to be once you get to your doctor’s office: if the doctor is backed up and running late, you could be in for a long wait, which is a logistical problem if you’re trying cram an appointment into a lunch hour or between jobs. Some of us may not think twice about cutting out early or showing up a little late in order to make a doctor’s appointment, but for some women this just isn’t an option.
Thinking back to getting my IUD, I count myself lucky that I live in Canada, where I received the consultation appointment, the IUD insertion, and a followup ultrasound to ensure it was in the correct position, all for free. The IUD cost $80 at the pharmacy, and 50% of that was covered by my employee prescription benefits. I have a job where I was able to take a scheduled, paid sick day on the day I got the IUD inserted and didn’t have to somehow work through the hours of horrendous cramping that followed the insertion.
My IUD has a typical-use failure rate of 0.2% and lasts 5 years. It cost me $40 CAD, some various mild inconveniences, and 8 hours of miserable cramps.
But what if my job didn’t have paid sick time? Or if I lived in the US without health insurance where IUDs can cost anywhere from $500 US – $1,000 US? Would I be able to afford the up-front cost even if does work out less expensive in the long term? Would I really “save up” for an IUD? And what if something went wrong? IUDs aren’t right for everyone, and you often won’t know if its right for you until you try it. If I had to have it removed, what would that cost?
The pill has a typical-use failure rate of 9%. An uninsured woman will pay between $540 US – $3,000 US for 5 years of birth control and $175 US – $1,000 US for 5 years of doctors appointments that may still leave her with an almost a 1 in 10 chance of getting pregnant. If she’s married or in a long term relationship, that cost may get rolled into the household costs, but it’s safe to assume that – at least while she’s single – she, like most women, will cover the cost of the pill on their own, even though accidentally making babies is a “2 to tango” game.
I found a box of 24 Durex condoms online for $13.99. If you want to protect yourself from STIs you need them anyway. You could have sex twice a week and only pay just over $300 for 5 years of birth control, at significantly less hassle, and can probably get the guy to pay for at least half (hey, he’s the one who’s wearing them!). Sure the typical-use failure rate is 18% but you’re a condom pro so you’ll just be super careful and get close to that 2% perfect use score, right? Split the difference between perfect use and typical use of a condom, and you’re around that 9% of the pill, right?
With the Affordable Care Act in the US, some women have reported they’re still getting charged for birth control they should be getting for free. Casey Gueren over at Buzzfeed wrote up a helpful list of what you can do if you’re still paying when you shouldn’t be. But if you’re working 2 or 3 jobs just to make ends meet, you’re probably not going to have the time or energy to argue with your pharmacist, make those phone calls, or file those appeals. Not when you can grab the $13.99 box of condoms right off the shelf, which is starting to look like pretty good odds. It comes with no arguments, no sitting on hold, no paperwork to sift through, no doctors offices to wait in, no boss to negotiate time off work with. So fast, easy, and affordable by comparison, that there really isn’t much of a choice, is there?