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Health care was a recurring theme throughout President Joe Biden’s 2023 State of the Union address on Capitol Hill this week. He took a victory lap on recent accomplishments like capping prescription drug costs for seniors on Medicare. He urged Congress to do more, including making permanent the boosted insurance premium subsidies added to the Affordable Care Act during the pandemic. And he sparred with Republicans in the audience — who jeered and called him a liar — over GOP proposals that would cut Medicare and Social Security.
Meanwhile, abortion rights advocates and opponents are anxiously awaiting a federal court decision out of Texas that could result in a nationwide ban on mifepristone, one of two drugs used in medication abortion.
This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sarah Karlin-Smith of the Pink Sheet.
Among the takeaways from this week’s episode:
President Joe Biden’s State of the Union address emphasized recent victories against high health care costs, like Medicare coverage caps on insulin and out-of-pocket caps on prescription drug spending. Biden’s lively, informal exchange with lawmakers over potential cuts to Medicare and Social Security seemed to steal the show, though the political fight over cutting costs in those entitlement programs is rooted in a key question: What constitutes a “cut”?
Biden’s calls for bipartisanship to extend health programs like pandemic-era subsidies for Affordable Care Act health plans are expected to clash with conservative demands to slash federal government spending. And last year’s Senate fights demonstrate that sometimes the opposition comes from within the Democratic Party.
While some abortion advocates praised Biden for vowing to veto a federal abortion ban, others felt he did not talk enough about the looming challenges to abortion access in the courts. A decision is expected soon in a Texas court case challenging the future use of mifepristone. The Trump-appointed judge’s decision could ban the drug nationwide, meaning it would be barred even in states where abortion continues to be legal.
The FDA is at the center of the abortion pill case, which challenges its approval of the drug decades ago and could set a precedent for legal challenges to the approval of other drugs. In other FDA news, the agency recently changed policy to allow gay men to donate blood; announced new food safety leadership in response to the baby formula crisis; and kicked back to Congress a question of how to regulate CBD, or cannabidiol, products.
In drug pricing, the top-selling pharmaceutical, Humira, will soon reach the end of its patent, which will offer a telling look at how competition influences the price of biosimilars — and the problems that remain for lawmakers to resolve.
Also this week, Rovner interviews Kate Baicker of the University of Chicago about a new paper providing a possible middle ground in the effort to establish universal health insurance coverage in the U.S.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Having spent its entire first week choosing a speaker, the Republican-led U.S. House finally got down to legislative business, including passing two bills backed by anti-abortion groups. Neither is likely to become law, because they won’t pass the Senate nor be signed by President Joe Biden. But the move highlights how abortion is sure to remain a high-visibility issue in the nation’s capital.
Meanwhile, as open enrollment for the Affordable Care Act nears its Jan. 15 close, a record number of people have signed up, taking advantage of renewed subsidies and other help with medical costs.
This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Alice Miranda Ollstein of Politico, and Sarah Karlin-Smith of the Pink Sheet.
Among the takeaways from this week’s episode:
The House now has a speaker after 15 rounds of full-chamber roll call votes. That paved the way for members to be sworn in, committee assignments to be made, and new committee chairs to be named. Cathy McMorris Rodgers (R-Wash.) and Jason Smith (R-Mo.) will be taking the helm of major health committees.
McMorris Rodgers will lead the House Energy and Commerce Committee; Smith will be the chairman of Ways and Means. Unlike McMorris Rodgers, Smith has little background in health issues and has mostly focused on tax issues in his public talking points. But Medicare is likely to be on the agenda, which will require the input of the chairs of both committees.
One thing is certain: The new GOP-controlled House will do a lot of investigations. Republicans have already reconstituted a committee to investigate covid-19, although, unlike the Democrats’ panel, this one is likely to spend time trying to find the origin of the virus and track where federal dollars may have been misspent.
The House this week began considering a series of abortion-related bills — “statement” or “messaging” bills — that are unlikely to see the light of day in the Senate. However, some in the caucus question the wisdom of holding votes on issues like these that could make their more moderate members more vulnerable. So far, bills have had mostly unanimous support from the GOP. Divisions are more likely to emerge on topics like a national abortion ban. Meanwhile, the Title X program, which pays for things like contraception and testing for sexually transmitted infections, is becoming a hot topic at the state level and in some lawsuits. A case in Texas would restrict contraception availability for minors through this program.
It’s increasingly clear that abortion pills are going to become an even bigger part of the abortion debate. On one hand, the FDA has relaxed some of the risk evaluation and mitigation strategies (REMS) from the prescribing rules surrounding abortion pills. The FDA puts these extra restrictions or safeguards in place for certain drugs to add additional protection. Some advocates say these pills simply do not bring that level or risk.
Anti-abortion groups are planning protests in early February at large pharmacies such as CVS and Walgreens to try to get them to walk back plans to distribute abortion pills in states where they are legal.
A growing number of states are pressuring the Department of Health and Human Services to allow them to import cheaper prescription drugs from Canada — or, more accurately, importing Canada’s price controls. While this has long been a bipartisan issue, it has also long been controversial. Officials at the FDA remain concerned about breaking the closed supply chain between drugs being manufactured and delivered to approved U.S. buyers. The policy is popular, however, because it promises lower prices on at least some drugs.
Also in the news from the FDA: The agency granted accelerated approval for Leqembi for the treatment of Alzheimer’s disease. Leqembi is another expensive drug that appears to work, but also carries big risks. However, it is generally viewed as an improvement over the even more controversial Alzheimer’s drug Aduhelm. Still to be determined is whether Medicare — which provides insurance to most people with Alzheimer’s — will cover the drug.
As the Affordable Care Act enrolls a record number of Americans, it is notable that repealing the law has not been mentioned as a priority for the new GOP majority in the House. Rather, the top health issue is likely to be how to reduce the price of Medicare and other health “entitlement” programs.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week that they think you should read, too:
The lame-duck Congress is back in Washington with a long list of bills it would like to pass and a short time to do it before Republicans take over the House majority in January. How many health-related items can be accomplished depends largely on how much money Congress agrees to spend overall, as it hashes out the annual federal spending bills.
Meanwhile, some of the remaining states that have not yet expanded the Medicaid program may be warming up to the idea, particularly North Carolina and Kansas, which have Democratic governors and Republican legislatures.
This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sarah Karlin-Smith of the Pink Sheet.
Among the takeaways from this week’s episode:
How much the lame-duck Congress manages to accomplish will partly hinge on whether congressional leaders opt for an omnibus spending bill — which would complete the unfinished spending bills through September 2023 — versus a continuing resolution, which would simply extend what’s already on the books into sometime in the new year. Bottom line: Health priorities are competing for a pot of money, but it’s unclear how large that pot will be. Some insiders describe it as a traffic jam.
At the top of that list are FDA reforms that didn’t make it into the prescription drug user-fee reauthorization bill that passed this year. Lawmakers fought to keep that measure “clean,” leaving the door open to tackle some leftover issues. What, if anything, will make the final cut is yet to be seen.
Other things on the lame-duck list include reversing a 4% scheduled cut to Medicare providers’ reimbursements; weighing proposals related to pandemic preparedness; addressing Medicaid funding for U.S. territories; addressing the end of the public health emergency; and scrutinizing telehealth policy.
Among the states that have yet to expand Medicaid under the Affordable Care Act, action is possible by those with a Democratic governor and Republican legislature — Kansas and North Carolina, in particular. Advocates are targeting such places because coverage for hundreds of thousands of people could be at risk, especially as the official end of the public health emergency looms. The financial well-being of some rural and safety-net hospitals also is in jeopardy.
Georgia is poised to expand Medicaid eligibility somewhat, but only to people who can prove they worked or did community service for 80 hours per month. This comes after a federal judge ruled that the Biden administration’s move to cancel a Trump administration-approved waiver was “arbitrary and capricious.” The only other Medicaid work requirement that has taken effect, in Arkansas, ended up taking coverage away from thousands of people who were eligible and working, due to its complicated reporting system.
Anti-abortion groups seem keen on finding creative ways to take aim at the so-called abortion pill, which recently became the most common method of ending pregnancy in the United States. Medication abortions are much more difficult for anti-abortion groups to target, because women do not have to go to a clinic to receive the drugs.
One lawsuit sought to force the FDA to rescind its approval of mifepristone, dating to 2000. Anti-abortion groups say the agency didn’t have the authority to approve the drug through the “expedited” pathway it chose.
Another strategy from anti-abortion groups claims that the use of abortion pills is contaminating wastewater and groundwater; they seek to deploy environmental laws to block the use of the drugs.
Despite Americans’ desire to put the covid-19 pandemic in the rearview mirror, the virus may have other plans. The Biden administration wants another $10 billion before the end of the year to pay for its anti-covid campaign, although even Democrats in Congress are not pushing hard for that funding. Meanwhile, governments and social media platforms are still struggling to address covid misinformation and disinformation.
Also this week, Rovner interviews KHN’s Fred Clasen-Kelly, who reported and wrote the latest KHN-NPR “Bill of the Month,” about a mysterious mishap during minor surgery. If you have an enormous or mystifying medical bill you’d like to share with us, you can do that here.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:
The Biden administration this week issued regulations aimed at fixing the Affordable Care Act’s “family glitch,” which has prevented families that can’t afford their employer insurance from getting subsidized coverage from the insurance marketplaces. The Obama administration had decided that only Congress could fix the glitch.
Meanwhile, open enrollment for Medicare begins Oct. 15, when beneficiaries can join or change private Medicare Advantage plans or stand-alone prescription drug plans. For the first time, Medicare Advantage plans are poised to enroll more than half of the Medicare population despite allegations that many of the largest insurers are getting billions of dollars in overpayments from the federal government.
This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachel Cohrs of Stat.
Among the takeaways from this week’s episode:
The “family glitch” arose because under ACA rules, people offered insurance through their workplace generally don’t qualify for subsidies if they instead purchase a policy on the marketplace — unless their work insurance is deemed unaffordable. That determination was made based on the cost of insurance for the individual worker, not what a family policy would cost. Since family policies are considerably more expensive than individual policies, they are often unaffordable for workers. The new federal regulation will take into account the cost of the family coverage.
Democrats were aware of this problem even as they passed the ACA. But this is an expensive change, and they were desperate to keep the cost of the bill below $1 trillion. They had promised to fix the “family glitch” but had not done it.
Many health policy experts believed the fix would need to be made by Congress, but the Biden administration opted to do it through regulation. Whether the regulation will face legal challenges from critics is not clear, but opponents may have a hard time proving they are being harmed by the new rule and have standing to bring a lawsuit.
Many seniors are happy with their Medicare Advantage plans, which often offer more benefits than traditional Medicare at a reduced cost. Enrollees, however, generally must stay within a plan’s network of health care providers.
Questions have been raised about federal payments to the plans. They were initially envisioned as a way to save money because lawmakers thought they would be more efficient than the government-run plan. But the benchmark formula for the plans now gives them more than 100% of what the government would pay for an average person in traditional Medicare, and the government pays the plans bonuses for taking on sicker patients.
Those bonuses have been the subject of numerous government investigations, whistleblower allegations, and some fraud lawsuits that allege the plans misidentify enrollees’ medical conditions to get higher reimbursements from the government. But while some watchdog groups have raised concerns, the Centers for Medicare & Medicaid Services has not made major changes to the reimbursement formulas, partly because Medicare Advantage has high patient satisfaction and bipartisan support on Capitol Hill.
As lawmakers get closer to Election Day next month, Democrats have trumpeted their support for abortion rights and hit hard at Republicans who supported the Supreme Court’s decision to overturn Roe v. Wade, which had guaranteed access across the country. The Democrats, however, have not been as active in making a case for their passage of the Inflation Reduction Act, which offered several popular changes, including caps on out-of-pocket drug expenses for Medicare beneficiaries, a provision allowing Medicare to begin negotiating the price of some drugs, and an extension of enhanced subsidies for people who buy insurance on the ACA marketplaces.
Democrat John Fetterman’s campaign for a U.S. Senate seat from Pennsylvania has been slowed down a bit by his recovery from a stroke he had earlier this year. He is back on the trail and is making live appearances, but he uses a computer device to help him translate conversations into written language because he says his auditory processing has not healed. Critics have said he should be more transparent with his medical records. Disability advocates have hit back against the criticism of Fetterman.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read:
The same federal judge in Texas who tried — unsuccessfully — to strike down the entire Affordable Care Act in 2018 has ruled that portions of the health law’s preventive care benefit package are unconstitutional. But it will be a long time, with many more court actions, before it becomes clear whether the decision will change how the law works.
Meanwhile, the U.S. Department of Veterans Affairs, after several weeks of deliberations, has decided to make abortions available to patients and some dependents in some circumstances. And in Michigan, a closely watched ballot measure on abortion scheduled for this fall may not get a vote after all because of a printing problem.
This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.
Among the takeaways from this week’s episode:
A decision announced this week by a federal judge in Texas could have a major impact on a popular provision of the Affordable Care Act that gives consumers no-cost access to a host of preventive care tests and treatments. Judge Reed O’Connor said the group that determines which services are eligible for that coverage does not have proper authorization from Congress.
O’Connor also ruled that employers with deep religious beliefs should not have to provide HIV prevention medications to workers if the employers believe those drugs encourage improper sexual behavior. The judge has not yet announced how he will suggest both these issues be remedied.
The Biden administration announced Thursday that it is overturning a rule implemented by the Trump administration that restricted immigrants’ ability to apply for permanent status in the U.S. if they had received government subsidies.
The U.S. Department of Veterans Affairs said it will now provide limited abortions for veterans and their eligible dependents at VA facilities in states that have restricted access to the procedure. The care will be available to veterans and dependents if the pregnancy is a result of rape or incest or is jeopardizing the life of the woman.
In Michigan, a state judge ruled that a 1931 ban on abortions is unconstitutional, but that is expected to be appealed. In the meantime, abortion-rights supporters are seeking to get a ballot measure that would guarantee access approved for consideration in the November election. The supporters have enough signatures, but the measure was drafted with a typographical error that could invalidate it. A court is expected to rule on the issue soon.
New covid-19 booster immunizations are rolling out to health centers and pharmacies across the country. The administration is encouraging anyone 12 or older (who hasn’t had a vaccination in the past two months) to get the shot. Administration health experts suggest this is the beginning of an effort to simplify the vaccination schedule and hope that most people will need only one shot a year after this. But that goal will depend on how the virus continues to mutate.
The Senate is back at work on Capitol Hill, and the House will return next week. The lawmakers still must come up with funding for the fiscal year that begins Oct. 1. Most people expect that they will turn to a temporary funding measure for the short term.
Three senators are out with covid, and one key Republican, Sen. Richard Burr of North Carolina, is absent because of a hip replacement. His absence comes at an inopportune time because he has worked with Democrats to try to push through a bill that extends the FDA’s ability to charge user fees to drugmakers to help pay for the agency’s assessments of drugs. He has also helped pull together a bill with Sen. Patty Murray (D-Wash.) to fund more efforts for public health preparedness.
Also this week, Rovner interviews KHN’s Lauren Sausser, who reported and wrote the latest KHN-NPR “Bill of the Month” installment, about a patient in need of a biopsy who did all the right things in advance and still got stuck with a giant bill. If you have an enormous or outrageous medical bill you’d like to send us, you can do that here.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:
The Democrats’ on-again, off-again budget bill is apparently on again, and it’s bigger than expected. In a surprise move, Senate Majority Leader Chuck Schumer announced an agreement with Sen. Joe Manchin (D-W.Va.) to expand the scope of the limited health bill that was headed to the Senate floor to also include climate change and some tax increases for corporations and certain wealthy Americans.
But the measure is still a fraction of what President Joe Biden and Democratic leaders had hoped for and does not include such high-profile health priorities as new Medicare benefits or expanded eligibility for insurance for people in states that did not opt to expand the Medicaid program.
Meanwhile, the Biden administration restored anti-discrimination protections in health care for LGBTQ+ individuals that the Trump administration had rolled back, while the Affordable Care Act returned to court in Texas, this time to hear a case challenging the health law’s requirement for preventive benefits.
This week’s panelists are Julie Rovner of KHN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.
Among the takeaways from this week’s episode:
The blockbuster announcement late Wednesday that Manchin had changed his mind and was willing to support a broader party-line bill to fund some of the president’s key priorities did not unveil any major changes to the health provisions agreed to earlier. Manchin previously said he’d sign on to Senate Democrats’ plan to allow Medicare to negotiate drug prices and keep the enhancements to premium subsidies for health policies purchased on the Affordable Health Care marketplaces.
The outline of the new Senate legislation, however, would extend those premium enhancements for three years, a year longer than what Manchin and Senate Majority Leader Chuck Schumer had previously agreed on. That means a renewal of those subsidies will not become a 2024 campaign issue.
Several big-ticket health items that progressives had sought in this legislation were left off, including new funding for home health care and a popular provision to lower consumers’ out-of-pocket costs for insulin. A separate bill would do that, but it has hit roadblocks in the Senate.
Passage of the bill is not assured. First, the Senate parliamentarian must confirm that its provisions are allowed under complicated rules that allow the Senate to pass spending and tax measures without the threat of a filibuster. Under that process, all 50 of the senators in the Democratic caucus must support the bill and the vice president would have to cast the tie-breaking vote. It’s not yet clear whether all senators are on board or if they can all be present for a vote in the next week. Several, including Manchin and Sen. Dick Durbin (D-Ill.), have announced they have covid and are in isolation.
Biden has recovered from his covid infection, according to the White House physician. While recuperating, he was careful to show that he continued to work and was doing quite well. And he made a point of noting that federal efforts he helped spearhead to make more vaccine and treatment options easily available would help others beat back an infection, too.
Some critics, however, suggested that Biden’s message about working while recuperating sent a bad signal because patients should be encouraged to rest and recuperate.
A new survey by KFF found that 4 in 10 parents of children under age 5 say they will not get their kids vaccinated against covid. This appears to be a byproduct of parents assuming the disease is not as threatening to little ones, their confusion about the studies of the vaccine, and their long wait for a vaccine.
In a surprising twist, it appears that Congress may pass a bill enshrining the right to gay marriage but not be able to pass a bill guaranteeing a woman’s right to contraception. The contraception bill has passed the House but has hit a roadblock in the Senate. Conservatives are concerned about complaints from anti-abortion groups who think some forms of contraception cause abortion.
A federal judge in Texas who has ruled against portions of the ACA before is presiding over a challenge to the law’s provision that guarantees insured people have no out-of-pocket costs for preventive care. The case could make its way to the Supreme Court, which has turned aside other efforts to undermine the ACA. But the power center has shifted in the court, so it’s not clear how the justices might look at this case.
Also this week, Rovner interviews Dr. Céline Gounder, an infectious disease doctor, a KFF senior fellow, and KHN’s editor-at-large for public health, about the ongoing monkeypox outbreak in the U.S. and around the world.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:
President Joe Biden is the latest top Washington official to test positive for covid-19, following Vice President Kamala Harris, Speaker of the House Nancy Pelosi, and Senate Majority Leader Chuck Schumer. But work continues, particularly on a Senate bill that could, for the first time, allow Medicare to negotiate prescription drug prices and cap seniors’ out-of-pocket medication costs.
Meanwhile, both supporters and opponents of abortion rights are struggling to find their footing in the wake of the Supreme Court’s overturn of the federal right to abortion in Roe v. Wade.
This week’s panelists are Julie Rovner of KHN, Shefali Luthra of The 19th, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachel Cohrs of Stat.
Among the takeaways from this week’s episode:
Although some Democrats and many political pundits are criticizing the Senate for scaling back the president’s Build Back Better agenda to be mostly a health care bill, the proposal in that bill to allow Medicare to negotiate prices for some drugs would be a major change that drugmakers have successfully fought for two decades.
The bill, which hasn’t been released in full, will include only those provisions that have been approved by Sen. Joe Manchin (D-W.Va.), because all 50 members of the Democratic caucus in the Senate will be needed to pass the bill. In addition to allowing price negotiations on 10 drugs in the first year, the legislation would penalize drugmakers that raise prices above the rate of inflation and limit Medicare beneficiaries’ out-of-pocket drug spending to $2,000 a year.
The bill is also expected to include provisions to extend for an additional two years the enhanced subsidies for premiums on health policies purchased through the Affordable Care Act’s marketplace. Those details have not yet been released.
Progressives have been dismayed at the administration’s lackluster answer to the Supreme Court’s decision overturning Roe. Even as the White House notes that there are limits to what the president can do, the administration has been more cautious than many expected in announcing how it plans to respond. For example, immediately after the Supreme Court released the decision, the administration said it would guard women’s access to medication abortions — but there has been little follow-up.
The Indiana doctor who treated a 10-year-old rape victim seeking an abortion is threatening a defamation lawsuit against the state’s attorney general, who incorrectly said on national television that she didn’t file the necessary paperwork.
The case of that 10-year-old has put anti-abortion groups on the defensive and suggested that they are split on how to handle situations like this. Some leaders suggest the child should have gone forward with the pregnancy, while other groups said people who have been raped should not have to carry a baby to term.
Texas Attorney General Ken Paxton is continuing his push to restrict abortion. The state basically shut down most abortions last September with a strict law that allows community members to sue doctors and others who help a woman get an abortion beyond six weeks of pregnancy. Now, Paxton is challenging the Biden administration’s statement that federal law entitles people seeking emergency care because of pregnancy problems to get an abortion. Paxton has said that federal law does not preempt the state’s restrictions.
Texas’ hard line on abortion could have an economic impact within the state. Some young people and companies are not in favor of the abortion policies and some are threatening to leave the state.
Also this week, Rovner interviews Dr. Jack Resneck Jr., a California dermatologist who is the new president of the American Medical Association.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:
For Stephanie Force, finding a birth control method that she likes and can get without paying out-of-pocket has been a struggle, despite the Affordable Care Act’s promise of free contraceptives for women and adolescent girls in most health plans.
The 27-year-old physician recruiter in Roanoke, Virginia, was perfectly happy with the NuvaRing, a flexible vaginal ring that women insert monthly to release hormones to prevent pregnancy. But her insurer, Anthem, stopped covering the branded product and switched her to a generic version in early 2020. Force said the new product left her with headaches and feeling irritable and short-tempered.
After talking to her OB-GYN, Force tried an IUD. But that made her feel worse: She had bad cramps, gained 10 pounds and developed severe hormonal acne. Plus, she was charged $248 for an ultrasound her provider used to guide the insertion of the device, a charge she successfully fought.
Force also considered a couple of birth control products approved in recent years: a non-hormonal vaginal gel called Phexxi and a vaginal ring called Annovera that can be used for a year. But Phexxi isn’t covered by her employer health plan, and she would owe a $45 copayment for Annovera.
Despite the ACA’s guarantees of free contraception coverage, Force’s experience illustrates that even for women whose health plans are subject to the law’s requirements, obtaining the right product at no cost can be onerous. New types of contraceptives aren’t automatically incorporated into the federal list of required methods that insurers use to guide coverage decisions. In addition, some health plans continue to discourage use of even long-established methods like IUDs by requiring providers to get approval from the plan before prescribing them.
Consumer advocates who have studied the issue say a process is spelled out in federal rules for women to get the contraceptive they need, but far too few people know that is an option.
Despite the ACA’s guarantees of free contraception coverage, Stephanie Force found out firsthand that obtaining the right product at no cost can be onerous. Force says she was unaware of any process she could have used to get the NuvaRing covered without cost sharing. Neither her health care provider nor the insurer mentioned the possibility.(Stephanie Force)
Ultimately, Force went back to the generic version of the NuvaRing, despite the side effects she continues to experience. She’d prefer to be on the branded NuvaRing, which didn’t give her problems, and the ping-ponging from method to method has left her exhausted and furious.
“I cannot believe what hoops I have had to jump through between September 2020 and June 2021,” Force said, “between switching from the generic NuvaRing to the IUD and then back, fighting my insurance and OB-GYN’s office on the ultrasound charge.”
In a statement, Anthem said, “Anthem health plans cover 222 contraceptive products at $0 cost share on our ACA Preventive List. We cover at least one product” in each of 18 categories of contraception methods approved by the FDA.
Contraception is a very personal choice, and what meets one woman’s needs may not meet another’s. If avoiding pregnancy is a woman’s top priority, a virtually fail-safe method like an IUD may be the right solution. But for someone who’s considering getting pregnant soon, a readily reversible method like a birth control pill might be the best option. Side effects are important to consider as well, since women respond differently to the hormones in various birth control products.
Before the ACA required no-cost birth control coverage, researchers estimate, up to 44% of women’s out-of-pocket health care spending went toward contraceptives. The ACA required most commercial health plans to cover a comprehensive list of FDA-approved methods without charging women anything. Church plans and religious nonprofits as well as employers and schools that object to contraception are exempt from the coverage requirements. Plans that were grandfathered under the law are also exempt. Uninsured women don’t benefit from the mandate either.
But the federal rules do not require health plans to cover every contraceptive. After the ACA passed in 2010, the federal Health Resources & Services Administration developed guidelines for women’s preventive services. Those guidelines say women should have access without cost sharing to a list that covers the 18 FDA-approved methods, including oral contraceptives, vaginal rings and cervical caps, IUDs, implantable rods and sterilization. Under federal rules, health plans must cover at least one product in each category.
But neither the HRSA guidelines nor a birth control chart published by the FDA addresses newer methods, including the gel Phexxi, which regulates vaginal acidity to reduce the odds a sperm reaches an egg. It was approved by the FDA last year.
“There’s a real need for new guidance that keeps up with new methods,” said Mara Gandal-Powers, director of birth control access at the National Women’s Law Center.
Many insurers have balked at covering Phexxi, said Rameshwari Gupta, director of strategic markets for Evofem Biosciences, which markets Phexxi. A box of 12 single-use applicators — consumers use one before having sex — costs $267.50 without insurance, she said.
“When I started talking to payers, they all said, ‘Where are you on this FDA chart?’” she said.
According to an FDA spokesperson, the birth control chart is for consumer education purposes only and “was not created with the intent of driving coverage decisions.” The agency is in the process of updating it.
In a statement, HRSA said it is reviewing the evidence on contraceptives and expects to complete its review late this year. If it opts to make revisions, it will publish draft recommendations to update the women’s preventive services guidelines. These will be finalized after a public comment period and become effective a year later.
At this point, health plans consider Phexxi a spermicide and are required to cover only one type of spermicide without cost sharing, said Kristine Grow, a senior vice president at AHIP, a health insurance trade organization.
“If Phexxi is indeed considered a new ‘method’ of contraception, both the FDA and HRSA would need to make this clear,” she added.
The vaginal ring Annovera, approved by the FDA in 2018, is typically covered by health plans, according to Grow, though it may not be available without cost sharing. The average retail price is $2,457 a year, according to GoodRx.
One way plans have made it difficult for women to access certain contraceptives, even those on the list of approved methods, is by requiring that their providers get approval from the insurer first, often by providing documentation that the product is medically necessary.
Under UnitedHealthcare’s coverage policy for Phexxi, for example, before coverage will be authorized, members must have documented reasons that they are unable to use eight other contraceptive methods, including oral contraceptives, the contraceptive patch, a vaginal ring, injections and spermicides. Providers also must attest that they have counseled patients that Phexxi is less effective at preventing pregnancy than some other methods.
In a statement, UHC said it covers “a broad array” of generic and brand-name options, and it follows scientific evidence to develop its list.
Yet consumers have a way to get the specific drug that is most appropriate for them, according to a report by the National Women’s Law Center.
Under federal rules, if a doctor or other health care provider determines that a patient needs a particular contraceptive, even if it’s not on the list of approved products for the patient’s plan, the insurer is required to have an expedient process for the patient to seek a waiver.
“It’s not up to the insurance company whether to cover that method; it’s up to the provider,” said Adam Sonfield, executive editor for policy analysis at the Guttmacher Institute, a research and advocacy organization focused on women’s reproductive health.
But according to the National Women’s Law Center report, many insurers, patients and their providers aren’t aware of the requirement, and state agencies don’t enforce these so-called exceptions policies.
If patients run into trouble getting the method they want, “we typically recommend filing an appeal with their insurance provider,” said Gretchen Borchelt, vice president for reproductive rights and health at the National Women’s Law Center.
Stephanie Force said she was unaware of any process she could have used to get the NuvaRing covered without cost sharing. Neither her health care provider nor the insurer mentioned the possibility.
She recently had an appointment with a new provider, who she hopes will be a better advocate for her.
