On July 8, the Supreme Court made it easier for employers to deny contraception coverage to their employees on religious or moral grounds.
The Affordable Care Act mandates that employers must provide coverage for birth control at no out-of-pocket cost. Houses of worship are exempt from this requirement. Religiously affiliated organizations such as universities and hospitals, and some for-profit companies, have had an accommodation that allows them to opt out of directly paying for birth control; if they give notice of their objection, their health insurer would cover the cost.
But the new decision, in which Justices Ruth Bader Ginsburg and Sonia Sotomayor dissented, allows more employers to refuse to provide health insurance that covers the cost of contraception. Now virtually any employer, including publicly traded companies, can seek an exemption from the Trump administration based on religious objections. So can religiously affiliated universities that provide health insurance to students. Nonprofits and companies that aren’t publicly traded can also seek an exemption by claiming moral objections.
What this means is that between 70,500 and 126,400 people could lose access to contraception, according to government estimates that Ginsburg cited in her dissent. The ruling will have significant negative impacts on people’s health, says Debra Stulberg, the chair of the University of Chicago’s department of family medicine.
Being unable to access birth control puts people at risk of becoming pregnant before they’re ready to be parents, when their health makes it unsafe for them to be pregnant, or when they don’t have the financial resources to care for more children, she points out. “As a doctor, I see that birth control is essential healthcare in order for my patients to be as healthy as possible.”
The Centers for Disease Control and Prevention estimate that, as of 2011, about 45 percent of pregnancies in the United States were unintended. Pregnancy can come with a wide range of health problems, from urinary tract infections to depression and preeclampsia. Giving birth can cause lasting complications and is sometimes fatal. In the United States, 658 women died in 2018 as a result of complications from pregnancy or giving birth. This means the country has a maternal mortality rate of 17.4 deaths per 100,000 live births—a dismal rate compared with similarly wealthy countries.
“Pregnancy is sometimes a very wanted event in life, and even in those circumstances it can put a real strain on your health,” Stulberg says. “For some people it’s the riskiest health decision they’ll ever go through, and so not being able to have a say in if and when you become pregnant really adds to that; it can put people…in risky health situations.”
Unplanned pregnancy can also take a toll on people’s emotional wellbeing, says Aparna Sridhar, a professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA. “There’s innumerable consequences for unintended pregnancy—not just looking at it from the physical health perspective but also mental health and emotional health.”
Pregnancy can also be particularly dangerous for people with other underlying conditions. For Stulberg, one especially vivid memory is of a patient with type 1 diabetes. Her pregnancy was planned and, although there were a number of complications, her baby was ultimately healthy. Shortly after giving birth to her son, this woman got an IUD.
“It was a really good thing that she did, because one of the things that the pregnancy did in conjunction with her type 1 diabetes is it put a real strain on her kidneys,” Stulberg says. Within a few months, she had developed kidney failure and was on dialysis. “I think a second pregnancy would have been extremely high-risk for her.”
Most people who get pregnant won’t wind up on dialysis. Still, this woman’s story illustrates why birth control is so important and in some cases lifesaving, Stulberg says—especially as COVID-19 continues to circulate around the U.S. Pregnant people who contract the disease are more likely to be hospitalized, according to the CDC. And, contraceptives such as the pill, implant, shot, and hormonal IUD have many uses beyond preventing unwanted pregnancy. They can treat a number of conditions such as abnormal bleeding, menstrual pain, acne, endometriosis, and polycystic ovary syndrome.
“There’s so many other benefits for the hormonal methods,” Sridhar says. “With [this decision] we are not only harming women who are trying to avoid unintended pregnancy, but also a broader set of people who are depending on this birth control for other health care reasons.”
The Supreme Court’s decision will disproportionately harm people who already experience the highest rates of unintended pregnancy, she says, including those who have low incomes, are between the ages of 18 and 24, or are people of color.
The majority of people in the U.S. get their insurance through their employer, Stulberg notes. Although some people can afford to pay for the pill, IUD, or other forms of contraception out-of-pocket, many cannot. “If your insurance doesn’t cover it, that basically means it’s out of reach,” Stulberg says. “My concern is this [ruling] creates a loophole you can drive a bus through—that any employer that doesn’t want to cover contraception for any reason could claim that it’s a moral reason and could opt out.”
On the other hand, many human resources professionals at large companies that Stulberg has spoken to for her research on contraception have expressed gratitude for the ACA’s mandate. These employers don’t want to have to negotiate with insurance carriers about whether contraception coverage is provided, she says.
“I hope most of them will not opt out,” she says. “I hope that they will recognize that comprehensive reproductive healthcare is good for their employees, good for the workforce, and good for the health of the population.”
According to the Guttmacher Institute, a nonprofit focused on policy and research on sexual and reproductive health, an estimated 99 percent of sexually active women in America between the ages of 15 and 44 have used a contraceptive method other than natural family planning, which involves estimating the most and least fertile days of a menstrual cycle. On top of everything else, protecting access to birth control is particularly important in the midst of the COVID-19 pandemic, Stulberg and Sridhar say.
“The nation’s unemployment rate is rising higher and there’s economic stress and there’s social distancing, the health care infrastructure is really strained—there are already so many existing obstacles to healthcare in general,” Sridhar says. Now is a time when we should be removing barriers and addressing inequities that stand between people and health care, she says. “I’m appalled at these policies which actually work the other way.”
Birth control is also a key part of protecting frontline workers during the pandemic, Stulberg says. “The country has at times expressed real gratitude for frontline health care workers, for delivery people, for service workers who are showing up for their jobs even in the face of some risk,” she says. Allowing employers to deny these workers coverage undercuts that support, Stulberg believes. “Why would we want to put one more hurdle in front of people getting their own healthcare needs met when they’re out there providing essential services to the rest of us?”