How has the ACA affected contraceptive coverage?
Before the Affordable Care Act’s (ACA) requirements for contraceptive coverage went into effect in 2012, most employer plans did in fact cover contraceptives — 85 percent of large employers and 62 percent of small employers did so in 2010. This was largely the result of a 2000 ruling by the Equal Employment Opportunity Commission, which held that the Civil Rights Act required employers that cover preventive prescription drugs and services to also cover prescription contraceptives. In addition, more than half of states had laws requiring private plans to cover contraception for health plans that fall under their jurisdiction — individual-market, small-employer, and fully insured large-employer plans.
However, the range of coverage and cost-sharing requirements for contraception were highly variable: women across the country had different contraceptive benefits depending on where they lived and the specifics of their insurance plan.
The ACA was the first law to standardize contraceptive coverage across all private health plans, including individual and all employer plans, except for those plans that were grandfathered in. This happened through the ACA’s requirement that all health plans cover recommended preventive and women’s health services without copayments, coinsurance, or deductibles. Under this ACA provision, the Health Resources and Services Administration designated all FDA-approved contraceptives as evidence-based preventive services that must be covered. These regulations improved the affordability of contraceptive services (including counseling) for all women in private plans beginning in August 2012.
By 2021, nearly 62 million women ages 18 to 64 could access birth control through their health plan with no out-of-pocket costs, saving nearly $1.4 billion every year in out-of-pocket spending on the contraceptive pill alone. The ACA led to greater use of contraceptives and provided women with the freedom to choose methods that fit their personal and medical needs. On average, contraceptives accounted for 30 percent to 44 percent of a woman’s total health care out-of-pocket spending before the ACA, but dropped to 11 percent to 22 percent after the law’s enactment. Women with low incomes who were privately insured, who tend to have higher rates of unintended births compared to those with higher incomes, saw the most precipitous decline in births post-ACA.
Can employers get exemptions from covering contraceptives?
In implementing the ACA requirement for contraceptive coverage, the U.S. Department of Health and Human Services excluded churches and other houses of worship from complying with the law’s provisions. Later, in 2013, an amendment further allowed nonprofit entities with religious objections, such as nonprofit hospitals, schools, universities, and charities, to elect an accommodation. This meant their employees could have access to contraceptive services without cost sharing through the insurer, sparing the employer from having to pay for those services.
Lawsuits were filed by both for-profit and nonprofit employers to expand these accommodations. In May 2016, the Supreme Court proposed that the parties come up with a compromise to allow organizations to exercise their religious beliefs while ensuring that their employees still “receive full and equal health coverage, including contraceptive coverage.” However, such a compromise could not be reached during the Obama administration.
In 2018, the Trump administration issued regulations expanding the contraceptive coverage exemption to all nonprofit and closely held private employers with moral objections rather than just religious objections. Ninety percent of U.S. businesses are closely held private entities. Several states filed lawsuits to challenge these expanded exemptions. In 2020, however, the U.S. Supreme Court determined they were compliant with the law, potentially depriving millions of women of no-cost contraceptives.
Which contraceptive services doesn’t the ACA cover?
Under federal rules, plans cannot favor one contraceptive method over another. For example, plans cannot cover birth control pills and not cover IUDs. But they can apply formularies (a list of preferred brands or generics) or impose utilization controls, such as requiring prior approvals, within a method category. This could, for example, effectively favor one brand of birth control pills over another. However, insurers must cover without cost sharing any provider-recommended contraceptive. The rules do not require plans to cover contraceptives for men, even if they have a prescription. This represents a major gap in coverage, especially because condoms are the only method that can protect against sexually transmitted infections.
Under federal rules, health plans are not required to cover nonprescription or over-the-counter (OTC) contraceptives like spermicides, sponges, or OTC emergency contraceptive pills. However, OTC formulations must be covered by insurers if they are prescribed. In July 2023, a contraceptive pill called Opill was approved by the FDA for OTC purchase, but private plans are not required to cover it. Without insurance covering OTC products, access may be limited. A three-month pack of Opill, for example, or a single dose of Plan B emergency contraceptive can cost up to $50.
How have states enhanced federal protections for contraceptive coverage?
Nine states require health plans they have jurisdiction over to cover at least some OTC contraceptive products without a prescription, but some explicitly exclude non-drug-based methods such as condoms, and some are limited to emergency contraceptives. The broad language on OTC contraceptives in some state laws can encompass coverage of OTC birth control pills without prescription.
Other state-based enhancements of federal contraceptive coverage laws include:
What could happen if federal laws protecting contraceptive coverage are weakened?
In the absence of federal protections, women’s access to contraceptive services would depend on a patchwork of state protections. And since states don’t have jurisdiction over employers who self-insure (i.e., use their own revenues to cover insurance claims), millions of women would be left out. In 2024, only 31 states and D.C. required insurers to provide coverage of FDA-approved contraceptive drugs and services, and there was state-to-state variation in requirements for cost sharing and prescriptions. Thirty-two states did not have any law prohibiting cost sharing. Since Roe v. Wade was overturned, some states have threatened access to IUDs and emergency contraceptives in two ways:
- Some state regulators and legislators mistakenly define IUDs and emergency contraceptives as abortifacients — methods that terminate an established pregnancy — rather than contraceptives, which are methods that prevent pregnancy in the first place.
- Some state abortion bans vaguely define the start of pregnancy such that any attempt to prevent the fertilization of an egg through contraception can be considered unlawful.
In the wake of the Supreme Court decision overturning Roe v. Wade, ensuring and strengthening affordable access to contraceptive choices is more critical than ever. Nearly six in 10 employed adults say that coverage of family planning services in employer health plans drives their loyalty to their company. Nearly eight in 10 women, eight in 10 Catholics, and six in 10 men agree that birth control should be a required benefit for all health insurance plans. Three-quarters of all voters believe affordable birth control is important for economic security and gender equality. Across genders and political and religious beliefs, most Americans support the widespread coverage of contraceptive services.
