4 Conceiving the Reality of Women’s Reproductive Healthcare

A Critical Look at How the ACA's Contraceptive Mandate Impacted Access to Women’s Reproductive Health Services

Shykell Ledford; Kristen VanLeeuwen; and Logan Waechtler

Among the Affordable Care Act’s (ACA) controversial provisions, one requirement relating to contraception is especially contentious. Although the provision’s text lacks mention of “contraceptive care,” that is exactly what one section of the ACA compels. The law reads that employers must provide coverage for preventative care following certain Health Resources and Services Administration (HRSA) guidelines. In addition, this coverage must be provided without any cost sharing requirements. The HRSA guidelines essentially “mandate that health plans provide coverage for all Food and Drug Administration approved contraceptive methods” (Little Sisters of the Poor vs. Pennsylvania, Slip Opinion, 2020, p. 1). Thus, the “Contraceptive Mandate” was born.

The exceptions to this Mandate make it even more controversial. Litigation regarding the Contraceptive Mandate has existed practically as long as the Mandate itself. Lawsuits have strengthened exemptions for employers with “sincerely held religious objections” and “sincerely held moral objections” from providing contraceptive care to their employees (Little Sisters of the Poor vs. Pennsylvania, Slip Opinion, 2020, p. 2). The rulemaking process that created these exemptions has recently been under scrutiny and found to “[run] afoul of the [Religious Freedom Restoration Act] RFRA,” meaning the process did not consider the religious implications satisfactorily. So, “the Government [is] required to eliminate the violation” and allow for other religious exemptions (Little Sisters of the Poor vs. Pennsylvania, Slip Opinion, 2020, p. 46).

This research project considers the extent to which the Contraceptive Mandate has been successful at realizing its presumed goals. We collectively believe that as a policy matter, the Contraceptive Mandate was a step in the right direction and support the Mandate because we believe individuals should be permitted to exercise their reproductive rights via contraceptive care. This type of care is not limited in benefiting only women; non-binary, transgender, gender non-conforming, and others should also have improved and equal access to contraceptive care. Furthermore, we trust in the positive externalities that arise when an individual is in control of their family planning resources. In short, we orient our study from a place of support for the Mandate and we endeavor to know if the Contraceptive Mandate is achieving its goals. In this study, we seek to answer the question: How did the ACA’s Contraceptive Mandate impact access to reproductive healthcare?

To answer the question, we conducted interviews with three women’s health professionals who are experts in their fields. Although the sample was small, the interviewees provided valuable insights to the Contraceptive Mandate’s impact on access to reproductive healthcare. Specifically, the results of our study suggest how the Mandate helped with the progression of reproductive health services, how it inadequately addressed issues it set out to resolve, and the uncertainty of its future. Despite eliminating cost-sharing for contraceptives and increasing access to reproductive services, the Mandate did not adequately address issues of intersectionality and religion. Furthermore, inconsistent implementation of the Mandate and the legal ramifications that encompass it yield an unpredictable fate that has yet to be determined.

Literature Review

This section highlights several studies and articles that help contextualize our inquiry into the Contraceptive Mandate’s impacts on access to reproductive healthcare. First, the literature details a strong relationship between access to reproductive healthcare and improved quality of life. The positive externalities associated with improved access to reproductive healthcare are the basis for our assertion that the Contraceptive Mandate is an empowering and effective policy. Next, a review of the history of the Contraceptive Mandate and how it became what it is today. The Mandate needs to be explained to subsequently define what we understand the intended purpose of the Contraceptive Mandate to be.

With the intended outcomes of the Contraceptive Mandate determined and explained we will, in the following subsections of this literature review, establish the Contraceptive Mandate as an empowering and effective policy, but also note its failings when measured against the purposes that have been detailed. Lastly, this section will underscore the importance of conducting research with a critical feminist theory lens by examining the appropriate measures that should be taken during the research process.

As a precursor for reading the Literature Review and the other remaining sections of this research paper, we offer the following analysis of central terms and their definitions. Establishing the meanings for the fundamental concepts our research is built upon is essential. All of these terms warrant a thoughtful deliberation on connotation and the consequences of that meaning.

Definitions

For many decades, people, institutions, and organizations have struggled to define what the word health truly means. Health is an encompassing term that can include a variety of factors such as physical well-being, a good mental state, a body without noticeable disability, and more. The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, n.d.). For purposes of this research, we take this definition and apply it one-step further to define women’s health, which includes reproductive health that encompasses maternal, child, and hormonal health.

In addition to defining health, it was important that the term women is also defined to fully encompass the terminology of women’s health. The term women has evolved over time to include individuals from all lifestyles, sexual preferences, and more. An important consideration for defining women in our research is understanding the role of gender. At present, Merriam-Webster Dictionary (n.d.) defines female as “relating to, or being the sex that typically has the capacity to bear young or produce eggs.” For purposes of this study, we use the Merriam-Webster Dictionary’s definition of female to define women.

Gender is also an evolving concept. There are many individuals who define themselves as female who may not fall into our selected definition of women. It is also understood that there are those who are defined as female but do not associate themselves with that particular definition or label. Gender identity and language focused around gender identity is vitally important to today’s society. It grants a freedom and sense of identity to many who may not have it otherwise. However, for purposes of this study, we have chosen to narrow our focus to the above definition of women given limitations of time and research capacities.

Women’s health can encompass many aspects; however, contraception plays a large role when discussing the health of women. Contraception allows women to have control over their reproductive health and the ability to play an active role in their family planning (Bansode et al., 2020). Contraception is defined as the act of preventing pregnancy (Bansode et al., 2020). Contraceptives are therefore the devices, medications, procedures, and/or behaviors used to prevent pregnancy (Bansode et al., 2020). Those methods are technological advances that help to overcome natural biology. According to the Centers for Disease Control and Prevention (CDC), there are many options that can be used as contraceptives (CDC, 2020):

  • Intrauterine contraception (IUD)
  • Hormonal implant
  • Hormonal injection
  • Oral contraceptives (i.e. the pill)
  • Hormonal patch
  • Hormonal vaginal ring
  • Diaphragm
  • Male and female condoms
  • Spermicides
  • Fertility awareness-based methods (i.e. understanding the monthly fertility pattern)
  • Emergency copper IUD
  • Emergency contraceptive pills
  • Male and female sterilization (i.e. vasectomy, hysterectomy, tied tubes, etc.)

It is imperative that our definitions include one more vital concept to create a complete picture of items discussed throughout this given research study. The United Nations Population Fund defines reproductive health as “[a] state of complete physical, mental, and social well-being in all matters relating to the reproductive system. It implies that people are able to have a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so” (“Sexual & Reproductive Health,” n.d.). In order to maintain one’s reproductive health, individuals need access to accurate information regarding safe, effective, affordable, and acceptable contraception methods of their choice (“Sexual & Reproductive Health,” n.d.). For purposes of this study, the definition provided by the United Nations Population Fund will be used to define reproductive healthcare to ensure a streamlined process of analyzing and dissecting information.

Advantageous Results Associated with Access to Reproductive Healthcare

A person’s quality of life is reliably shown to improve with their access to reproductive healthcare (David & Kling, 2020; Rice et al., 2020). Women who are in control of their bodies in this way are free to fulfill other potentials (Planned Parenthood Fact Sheet, 2015). Authority over the decision to become pregnant is arguably the main benefit contraceptive care provides, but it is far from the only one. Non-contraceptive benefits include “cycle control, treatment of menstrual disorders, prevention of certain gynecological cancers, treatment of acne, and prevention of menstrual migraines to name a few —” ultimately, “improvement in these diagnoses can translate to quality-of-life benefits and decreased disease burden for women” (David & Kling, 2020, p. 887).

The literature further suggests that access to reproductive healthcare, especially contraceptive care, results in what economists and policy analysts refer to as “positive externalities.” A positive externality is realized when a third party (or parties) benefits from an action taken that they were not directly involved in. A prime example of this phenomenon is how society benefits when individuals exercise bodily autonomy in the reproductive healthcare realm. In addition to the advantageous outcomes experienced by such women themselves, the general population benefits in measurable ways (Becker, 2018). Perhaps most notably, “[f]rom a budgetary perspective; [contraceptive] use has been estimated to produce cost savings to public insurers of $1.30 to $7 per dollar spent, depending on the method. These are cost-savings on the same order as those of childhood vaccinations.”

Intended Outcomes of the Contraceptive Mandate

The key requirements of the Contraceptive Mandate are the elimination of cost sharing and the provision of certain healthcare services found in guidelines established by HRSA (Tschann & Soon, 2015). These services must be provided free-of-charge by insurance providers and incorporate services such as contraceptive methods, sterilization procedures, and patient education and counseling (DeBoer, 2015). The purposes and intentions of these requirements include the following (DeBoer, 2015; MacCallum-Bridges & Margerison, 2020; Tschann & Soon, 2015):

  • To reduce healthcare costs and improve the population’s health;
  • To help women because they have unique healthcare needs and burdens, which ultimately put them at a disadvantage in the workforce;
  • To address the risk of women who do not receive prompt prenatal care or who engage in high-risk behaviors because they do not know they are pregnant;
  • To avoid costs related to pregnancy for employers;
  • To improve social and economic statuses of women because they can focus more on their careers;
  • To help women achieve equal status as healthy and productive workers;
  • To eliminate the significant barrier to contraception of cost-sharing;
  • To reduce gender and health disparities, which consist of inequality in the workforce and inequitable access to reproductive care;
  • To decrease the number of unintended pregnancies.

The extent to which the Mandate has met these goals is arguable, with some thinking that it went too far. Specifically, advocates against the Mandate have said that it created a burden on businesses, especially those who have religious and moral objections to it. Part of the issue is found within the rulemaking process for executing the Mandate and another part is found in the requirement as finalized by HRSA.

First, DeBoer (2015) used the Childress and Gostin public health ethics framework to evaluate the rulemaking process. Under this framework, the government must justify public health policies (DeBoer, 2015). As a component of the framework, moral content considers the benefits, harms, utility, justice, autonomy, privacy, integrity, transparency, and trust within the process. If one of these is violated, then there must be a justificatory condition, which includes effectiveness, proportionality, necessity, least infringement, and public justification. Using this framework from a legal perspective, DeBoer (2015) concluded that there were many deficiencies in the ACA’s Contraceptive Mandate and that it could have used more work, especially considering the justification for infringing some of the moral content principles. In summary, DeBoer (2015) believed that there was not enough consideration of the religious impact of the Mandate and that HRSA should have considered the religious exemptions more thoroughly. They also should have followed a more transparent and accountable process.

 Second, the final religious exemption was also seen as insufficient. Although HRSA was concerned that expanding the exemption would impose religious views of employers on their employees, limit access to contraceptive care, and inhibit the use of those services, others felt they used a truncated rulemaking process to pass what they believed was best, and not what the majority wanted (DeBoer, 2015). Before the religious exemption was brought before the Supreme Court of the United States, the exemption only applied to nonprofit organizations who opposed all or part of the Mandate based on religious views and if they maintained themselves as religious organizations (DeBoer, 2015). However, the Supreme Court determined in Little Sisters of the Poor v. Pennsylvania (2020) that these religious exemptions now apply to all businesses whose owners have a religious objection to it. Organizations no longer need to be religious in nature to file for an exemption. This seems to protect the First Amendment right of freedom to religion, but at the same time it can potentially hinder women’s access to reproductive care.

 On the other hand, some people believe that the religious exemption should not exist at all. The intention of eliminating the religious exemption is so that the protections provided by the Mandate can reach as many women as possible. If one of the primary goals is to expand access to reproductive care for all women in the United States, then this is a valuable argument to consider. The situation is complex and riddled in legal issues. One would hope that a balance could be found between not unduly burdening religious organizations and expanding access to reproductive care. It is within this lens that we are critically aware of how women’s access should be impacted, which was considered during our interviews. For this reason, we are using the intentions of the Mandate described here as the standard of comparison for our interview responses.

Contraceptive Mandate Successes

There are important successes that the Contraceptive Mandate has achieved. “Multiple studies have shown that when contraceptive options are available at no cost, this leads to increases in contraceptive use, allowing more equitable access to all who need these medications for any health reason” (David & Kling, 2020, p. 887). The Contraceptive Mandate is primarily concerned with improving women’s access to contraceptive care. No-cost sharing is one tool that can be used to achieve this goal. The Contraceptive Mandate can be considered an effective policy. Since its inception, notable increases in the number of women using contraception—short and long term—have occurred (Carlin et al., 2016; Becker, 2018). Specifically, Carlin et al.’s 2016 study reveals a 90 percent increase (on average across treatment and control groups) of prescriptions for oral contraceptives filled after the Mandate was implemented. She notes, “[w]hen cost sharing for contraceptives fell to zero for women in plans that complied with the ACA’s [M]andate to eliminate that cost sharing, their rate of choosing prescription contraceptives rose much more than the rate for women in plans unaffected by the [M]andate” (p. 1614).

Contraceptive Mandate Limitations

The literature on the shortcomings of the Contraceptive Mandate includes extensive comment detailing logistical and knowledge-based failures. Studies show that even a shallow understanding of the Contraceptive Mandate, let alone a “basic understanding of contraceptive methods, how they work, and how they can be effectively used,” (Stidham et al., 2016, p. 668) is strikingly lacking among eligible women (Tschann & Soon, 2015). The Contraceptive Mandate is a nuanced policy that is under constant scrutiny and has been subject to many lawsuits that have significantly altered the consequences of it. The evolution of this law has yielded “increased difficulty [for] patients and their providers in accessing insurance benefits” (Tschann & Soon, 2015, p. 614). Besides the struggle found in tracking and comprehending the evolving law, logistical implementation failures exist:

Billing for non-contraceptive method indications, cost sharing for office visits that include non-contraceptive care, device/drug stocking, bundling of family planning and obstetric services at the time of delivery, and reimbursement are difficult to manage, track, and explain to patients. As standardized implementation processes are needed, some professional organizations have offered guidance on coding, billing, and managing supply issues. Even then, many providers lack the knowledge and skills necessary to provide the full range of ACA-mandated contraceptive methods and services. (Stidham et al., 2016, p. 668)

Lastly, on these practical implementation failures, Stidham et al. (2016) draws attention to the “political and ideological ‘blurring’ of contraception and abortion” (p. 667). Labeling this congruence as a “distraction and disservice” to women, noting that it may not accurately “reflect [their] views of and priorities for reproductive health policy” (p. 667). Politics is ultimately a heavy-handed player in the Contraceptive Mandate’s efficacy.

In the discourse surrounding the Contraceptive Mandate, there is also considerable discussion regarding how the Contraceptive Mandate fails to provide reproductive healthcare to demographics that could substantially benefit from improved access. This type of failure is actualized by the law’s intersectional apathy.

The premise of intersectionality theory, first articulated by feminists of color, is that social differentiation is achieved through complex interactions between markers of difference such as gender, race, and class. In order to comprehend how an individual’s access to social, political, and economic institutions is differentially experienced, it is necessary to analyze how markers of difference intersect and interact. (Darity, 2008, p. 114)

The literature here repeatedly stresses “sociodemographic characteristics disparities in ACA awareness” (Stidham et al., 2014, p. 10). In short, the Contraceptive Mandate is a progressive, empowering, and effective policy for “socially advantaged” women (Stidham et al. 2014, p. 8). Patients who are young, nonnative English speakers, poor, of racial/ethnic minority status, and/or less educated are disproportionately unaffected by the Contraceptive Mandate (Tschann & Soon, 2015; Stidham et al. 2014; Becker, 2018). Although the Contraceptive Mandate has significantly improved access to reproductive healthcare for American women, “the law applies only to private plans and leaves behind those at greatest risk for unintended pregnancy—uninsured women and women with pre-existing Medicaid plans—who are disproportionately younger, poor, and of racial/ethnic minority status” (Stidham et al., 2016, p. 668).

The progressiveness of this law fails because it does not adequately address the many other statuses women occupy aside from their sex. Women disproportionately uninformed about the Contraceptive Mandate “are the same groups who experience disproportionately high rates of unintended pregnancy, adverse birth outcomes, cancer-related mortality, and inequities in access to care. In other words, women who might benefit the greatest from the ACA were particularly uninformed” (Stidham et al., 2014).

Examining the Contraceptive Mandate with Critical Feminist Methods

Critical perspectives lend themselves to the deconstruction of orthodox thinking (Riccucci, 2010). Critical theory centers on socially constructed power dynamics within relationships and analyzes the issues of power used in governance circumstances. Critical theory also focuses on how to empower marginalized individuals or groups through the development of self-awareness, critically examining their life situations, and consciousness-raising (Kezar, 2003). In this case, the power that men have seemingly held over women when it comes to determining what they should do with their bodies is encompassed by socially constructed gender roles and norms. Gender roles become an important consideration for women’s healthcare in the U.S. because women have not historically been in positions of power to direct policy regarding health services they can obtain. Although this has changed to some degree with the modern feminist movement, examining issues from a critical feminist perspective can yield valuable insights, especially as it relates to reproductive care.

The application of feminist theory to our research is an essential component. Montell (1999) discussed five epistemological principles found in feminist research that are applied in this study: (1) the significance of gender; (2) challenges the norm of objectivity and separation between researcher and the researched; (3) consciousness-raising is a methodological tool; (4) the emphasis of evolution of patriarchal institutions and empowerment of women; and (5) concern for ethical implications of the research. This research considers how women have unique healthcare needs that men cannot fully understand without being a woman or without engaging in consciousness-raising.

Not only does feminist theory help shape our conclusions of the Contraceptive Mandate and access to reproductive care, but it also guides our research process. Feminist theory is not uncommon in qualitative studies and has evolved over time in interview-based research. For example, DeVault (1987) stressed the importance of giving female interviewees a voice, to allow them to piece together their own stories and experiences in their own words without much intervention by the interviewer. When researchers follow this strategy, they must listen around and beyond words. Relying on more than the spoken word in interviews, such as social cues and expressions, helps to construct a more complete story.

Research Design

This research is grounded in the Contraceptive Mandate of the ACA; using the purposes and intentions of the Contraceptive Mandate as a standard for comparison (DeBoer, 2015; MacCallum-Bridges & Margerison, 2020; Tschann & Soon, 2015). Although one purpose of the ACA was to expand access to health insurance and healthcare services (DeBoer, 2015), people should question if it generated more barriers than it set out to break down. Interpreting the various requirements within the ACA’s Contraceptive Mandate and its related rules for implementation is one way to unravel the problems surrounding women’s access to healthcare. Another way is by learning the perceived barriers to women’s access to healthcare according to experts in the field of women’s health. Together, the interpretations of perceived realities and intended outcomes of the Contraceptive Mandate can provide deeper understanding of the disparities in women’s healthcare, especially as they relate to contraceptive care.

Consequently, a critical discourse analysis is a sound method to review the impact of the Contraceptive Mandate on reproductive care. This method was executed by our interpretations of interview discussions with key informants within the women’s healthcare field. These individuals include professionals who directly or indirectly assist women with reproductive care to varying degrees. The decision to interview women’s health experts rather than any woman who seeks reproductive care is based on the assumption that experts better understand the complexities of the Contraceptive Mandate and its implementation. However, we admit that interviewing any woman who is impacted by the Mandate could also provide valuable insights.

During the interview process, we encouraged unrestrained responses and clarified our subjective position in the research. This transparent approach did not impact responses from the interviewees and was one way to connect to them on a more personal level. Discussing potential impacts of the ACA’s Contraceptive Mandate within the interviews also allowed us to use consciousness-raising as a method to emphasize important issues within women’s reproductive care. Although the involvement of women in the development of the Contraceptive Mandate cannot be denied, it is important to recognize that women have traditionally been excluded in the development of public policy. It is from this critical standpoint that we are skeptical of whether the ACA has done enough for women’s reproductive care.

Research Sample

We conducted semi-structured interviews with three women’s health professionals from health-focused nonprofit organizations in Utah. Interviewee selection was a combination of convenience sampling within our professional networks and snowball sampling. More specifically, we started with two purposively selected interviewees. We asked these interviewees if they knew anyone else who could provide additional insights, resulting in a third interview. The interviewees are summarized through available characteristics in Table 1.

 

Table 1. Interviewee Characteristics
Interviewee Race and gender Other relevant characteristics
Participant 1 White female Works for a family planning advocacy program in Utah; Expertise in field of policy and education
Participant 2 White male Works for a family planning advocacy program in Utah; Trained OBGYN who specializes in contraception and abortion services
Participant 3 Black female Oversees community outreach for a Utah organization that focuses on providing education and services related to contraceptive and reproductive care

Each interviewee has an extensive background in women’s health. Additionally, all the organizations where they work help provide services to individuals who cannot afford contraceptive and reproductive services. To some degree, the organizations also strive to address the disparities in contraceptive care across race and economic status. To protect the identity of the interviewees, a consent form was created that each individual signed. Given that, identifying information was removed from the interviews in our discourse analysis.

Data Collection and Analysis

We followed a similar approach to data collection for our interviews used by Kennedy, Grewal, Roberts, Steinauer, and Dehlendorf (2014) in their study of barriers encountered by homeless women as they try to access women’s health services. Interview questions were designed with the intention of getting a broad yet detailed overview of the perceived impact of the Contraceptive Mandate (see the Appendix). Participants were asked questions related to their professional and educational background to understand how they became involved in the field of women’s healthcare and their understanding of the Contraceptive Mandate. Other interview topics included responsibilities they currently have related to women’s healthcare, if they have a clinical or academic role, if they interact with women directly and the frequency of those interactions, and—of course—the benefits and challenges that they have seen presented by the Contraceptive Mandate and its evolution in Utah. Interviews were conducted virtually, audio-recorded, and transcribed. Both verbal and written consent were obtained from interviewees prior to the interviews.

Once the data were retrieved, critical and content analyses based in interpretivism and critical theory were performed to draw conclusions on the impact of the Contraceptive Mandate on reproductive care. We collectively identified central themes during our evaluation of the interviews as they related to our standard so that our conclusions were consistent. We noted any consequences of the ACA within the interview responses that overlapped with our comparative standard. The themes that were most prevalent formed the foundation of our critical response to the Contraceptive Mandate and our proposed solutions.

Findings

The interview participants in this research project were few, but their poignant observations on the impacts the Contraceptive Mandate has had on access to reproductive healthcare were not. As researchers, we sought answers on the Mandate’s impacts by asking the participants open-ended questions regarding their professions and how their professional lives have been directly and indirectly affected by the Mandate. Their responses are organized here by the Mandate’s progression, then by its insufficient impacts, and lastly by their predictions for the future of the Mandate.

Progression Consequential to the Contraceptive Mandate

While the ACA’s Contraceptive Mandate created many benefits for individuals across America, one of the greatest benefits of the Mandate was that it provided no-cost contraceptives to those who qualified. Without insurance, contraceptive methods can range anywhere from $50 a month to $1,000 a year (“How Much Do Different Kinds of Birth Control Cost without Insurance?,” 2017). Implants average at a cost of $800, IUDs can start at $1,000, and the pill, the most inexpensive method, can still end up costing a woman upwards of $600 a year without insurance (“How Much Do Different Kinds of Birth Control Cost Without Insurance?,” 2017). All interviewees expressed their praises of the Mandate and the positive impact it had on many women who were able to safely afford various contraceptive methods, as well as benefit society as a whole. As articulated by Participant 1:

I think that there’s the more [perceived] benefit around what contraception is and the benefit that it provides to society as well as the fact that people can get no-cost methods…The ability to have multiple methods at no cost, that people can switch between, is a lifesaver when it comes to meeting people’s actual needs. 

In addition to no-cost saving methods introduced by the Mandate, affordable contraceptive options also served as another benefit to those who qualified under the Mandate. According to the National Institutes of Health (NIH), there are five main types of contraceptives available to individuals, which include long-acting reversible contraceptives (LARC), hormonal methods, barrier methods, emergency contraception, and sterilization (NIH, n.d.). Within each of those five types, there are several methods of contraceptives allowing individuals the opportunity to choose from upwards of 18 different methods to fit their lifestyle and health needs, if their insurance covers them. Through the Mandate, women were given the opportunity to not only choose a contraceptive at no cost, but they were able to choose a method that was appropriate for their lifestyle and needs at a given time in their reproductive life. Participant 3 admits that it is through the Contraceptive Mandate that a person now has more control over their body and health because individuals are now given the opportunity to choose what is right for them: “The ACA has just really given a person more control, more say, and bodily autonomy to fulfill their lives and just get the healthcare that they feel is necessary for them.”

In that same breath, it is also noted that not only did the Mandate provide individuals with the ability to choose a contraceptive method that was correct for them, but it also allowed people to change methods throughout their reproductive lifetime to fit whatever situation they may be in. With the Mandate covering various contraceptive methods for those who are qualified, the Mandate allowed people to make healthier decisions based on their body’s needs instead of a financial burden. While all interviewees expressed this important aspect of the Mandate, Participant 1 noted how key this particular point was in order for the Mandate to truly impact a person’s life:

So, the idea that it’s not just coverage of a pill, it’s not just coverage of something, but the ability to switch and change methods throughout the reproductive life course, is an enormous benefit to people because what worked for you one time might not work for you another time in your life. It’s very unreasonable to say that you should be able to use condoms throughout your life successfully if you had a great partner and now you have a coercive partner, or a partner who is allergic to latex, or maybe you got pregnant and had a baby and now you have a weird allergy. There’s so many different things that come up. The ability to have multiple methods at no cost, that people can switch between, is a lifesaver when it comes to meeting people’s actual needs.

Participant 2 also points out that not only do individuals have the ability to choose the correct contraceptive method being addressed by the Mandate, but it has also provided an opportunity for individuals to use more highly effective methods. By women using more highly effective contraceptive methods, such as IUDs or implants, women have the ability to take greater control over their reproductive and menstrual health. In Participant 2’s words:

Certainly as [the Mandate] has happened, it has facilitated the change to people using more highly effective methods of contraception. So more IUDs and implants [are] being used and more people [are] having that covered and more states…[are] having essential contraceptive initiatives where they are able to get it for less.

Through the ACA’s Contraceptive Mandate, we have witnessed that mindsets have shifted to include reproductive healthcare in primary care. Prior to the Mandate, the interviewees pointed out that many people saw reproductive healthcare as its own policy, separate from primary healthcare. However, all expressed how the Mandate has helped argue that reproductive care is part of women’s health, therefore making it part of primary healthcare as a whole.

I think that the main purpose of the Contraceptive Mandate was to make the argument and to take into broader context that reproductive healthcare is primary care. Even though contraception has been historically seen as only benefiting one sex, it actually benefits everybody. I think that a lot of times when we pass policy, we’re making a statement about what we believe as a society. I think that making that statement, that reproductive healthcare is primary care, has value to everybody. It deserves coverage. (Participant 1)

While some effects of the Mandate may be immediate, there are also benefits that take more time to be realized. Many positive externalities are byproducts of care through the ACA’s Contraceptive Mandate. As Participant 2 explains, by giving women more control over their bodies and more choices, they are able to not only advance in their workplace, but also take control over their aspirations, which in turn leads to greater outcomes and positive consequences on society itself:

If fewer people are having unintended pregnancies, more women are more likely to be in the workplace and have greater access to greater income earning potential and greater access to societal benefits and meet their educational and work aspirations and their family aspirations.

Digression Consequential to the Contraceptive Mandate

One impact of the Contraceptive Mandate that remains uncertain is the religious implication. Women deserve to have equitable access to quality contraceptive care. People should not impose their belief systems on women and limit their choices. In this vein, the interviewees all expressed concern about the religious implication of the Mandate. Participant 2 was the biggest critic of religion’s interference in reproductive care, which is expected as his background is in contraceptive care and abortion provision:

If we don’t say anything, the nature of the dialogue is that there [are] people that have, what I would consider, extreme religious beliefs that essentially try to block access to everyone and determine “this is what I believe and I am going to use that belief system to essentially prevent the majority of the population to getting access to what they determine themselves what they need.” That does not seem right or just to me…. And much of what they say to support that viewpoint…is not based on fact. It is essentially these internal dialogues that they have that they disseminate very widely with lots of enthusiasm and tons of passion to try and convince people what they believe is right.

Since the Supreme Court’s ruling on Little Sisters of the Poor v. Pennsylvania (2020), organizations do not have to justify much to receive the religious exemption. Before the case, only religious nonprofits could receive the religious exemption. However, now any organization whose owners purport a moral and/or religious objection to the Mandate can file for the exemption. Participant 1 and Participant 3 expressed concern over this change for qualifying for exemption. Even more alarmingly, Participant 3 suggested that organizations might use the ruling to file for the exemption under the façade of religious beliefs when truly it is just their personal belief:

Because now, all of a sudden, that meant that my employer now has the right to not cover contraceptives, depending on their religious or spiritual belief. So, if there are personal belief[s], [I] felt like it was, you know, in opposition to providing me, as their employee, healthcare. Now they can take it away.

Another barrier created by the Contraceptive Mandate is unrelated to its requirements, but rather how it has been executed. Implementation of the ACA, including this Mandate, is inconsistent across states. It is overwhelmed with legal issues and court cases that make it difficult to effectively implement. Part of the issue is the haphazard approach used in the rulemaking process. Some implications were not considered as much as they should have been, such as the religious exemption (DeBoer, 2015). All the interviewees discussed the difficulty of maneuvering the Contraceptive Mandate because of its complex and inconsistent implementation. They all agreed that it generates confusion and makes it difficult for women to receive proper care according to their contraceptive preference. As stated by Participant 1:

Unfortunately, a lot of times when you pass a policy, there isn’t an implementation component to that policy. It’s easy, for example, the state of Utah to say, “Oh, yeah! We’re expanding Medicaid!” and then nobody knows that Medicaid is expanded. And they have this very complicated form to fill out and then they have to find a doctor…then the doctor has to know how to give all of the methods and how to counsel them properly, and then they need to know how to provide that method, and that person needs to know how to utilize that method correctly.

Implementation also becomes difficult when funding is cut. Although not necessarily a consequence of the Mandate, clinics and doctors do not have enough resources, tools, funding, etc. Because of inconsistent implementation, there are structural issues that remain to be addressed. For example, Participant 3’s organization lost some of their funding from the Trump Administration’s policies and legal decisions surrounding the ACA and the Contraceptive Mandate:

We lost our Title X funding as part…. That’s why we have for the first time a co-pay of $10 for anybody who comes to our door seeking services. Before that, we didn’t have a copayment. Title X is what allowed us to not have to have that payment and to have funds—to have the sliding scale fee for our services. That was the direct impact, just from the Title X.

One of the most prevalent issues raised by Participant 1 and Participant 2 that persists even after the implementation of the Contraceptive Mandate is the “coverage gap”. This gap is related to who can receive Medicaid and varies according to a state’s expansion of Medicaid. Specifically, there is a gap in coverage where women make too much money to be covered by Medicaid but not enough money to receive quality health insurance. Consequently, these women have a difficult time affording contraceptive care. The Mandate applies to private health insurance plans. If women are in the coverage gap and do not have an insurance plan covered by the ACA, then it becomes difficult for them to receive contraceptive care, let alone a method that they prefer. Their choices then become limited because of income constraints.

If [women] are getting [contraception] at no-cost, otherwise they are trying to figure it out on their own and that, to me, is not a sensible approach. So, you know, any implementation of the program is going to be uneven along those lines. And then there are other challenges, right? Like, people are not able to enroll or they are just beyond the Medicaid limits, and in Utah those have come up quite a bit, but when I started I think they were…60 or 80 something percent of the federal poverty level. They were incredibly low. And then the federal poverty level is incredibly low. It is basically $1,000 a month for a single person or $2,000 for a family of four. (Participant 2)

The Contraceptive Mandate does not apply the same standards to grandfathered plans either. Grandfathered plans include any health insurance plan that was in effect before the passage of the ACA. They are permitted to continue offering the same coverage they offered before the law passed. As a result, women who have one of these plans might not have contraceptive coverage. At the very least, they may not receive no-cost contraception, which limits their choices. In the words of Participant 1:

For example, 20%-ish of plans in Utah were grandfathered into the ACA or grandfathered in and thus don’t require contraceptive provisions in the Contraceptive Mandate. So, we have a large proportion of people getting care through religious plans and other plans who were never required to have that coverage.

Intersectionality and the Contraceptive Mandate

The interviewees all noted disappointment with the Contraceptive Mandate for its failure to confront issues of intersectionality in its implementation. Intersectionality is recognizing and analyzing how multiple identifiers such as gender, race, class, and age are all interconnected and then reporting on how “these factors interact to shape lived experience” (International Encyclopedia of the Social Sciences, 2008, p. 114). The literature on this topic voiced dismay in the Contraceptive Mandate for not going far enough in aiding women who could find the most marginal benefit from improved access to reproductive healthcare. Participant 3 summarized what the problem of insufficient application of intersectionality theory can lead to:

We always look at how our social issues also impact the determinants of health…As we are dealing with the current COVID pandemic and the public crisis that is racism. We’ve known [about] the health disparities that exist for different marginalized communities—for black, indigenous, people of color, LGBTQI folks. A lot of the time these are the communities that are most impacted and [then] denied rights to equitable healthcare, or even basic human rights.

The interviewees specifically separated other identifiers (different from sex, which is arguably the only status that the Contraceptive Mandate addresses) and gave their perceptions on how the Contraceptive Mandate had negative impacts in acute assertions. All of the interviewees noted that racial inequality is a very prevalent factor, which affects access to reproductive care. Participant 1 stated, “We know for a fact that people who are black or people who are indigenous are a lot more likely to receive coercive counseling and care [in seeking contraceptive care].” Similarly, Participant 2 relayed that “Black women who are pregnant have a three-fold risk of dying within the next year relative to white women and infants also have a three-fold increased risk in mortality.” Those are striking and definitive statements from local women’s healthcare professionals that align with the literature on this subject, demonstrating that this issue is not centralized in any one location. Our same participant (Participant 3) that confessed their loyalty to examining how social issues impact the determinants of healthcare also elaborated on a startling connection between health and experiencing racism:

There are certain conditions that are common within the black community, high blood pressure being one. If we look at communities being left out, intentionally, this is going to target communities. Science has shown that the reason they say that high blood pressure is a common element within the black community is because it’s living under the stressors of structural racism—having this constant state of stress.

The Contraceptive Mandate does little to nothing to improve access to reproductive care specifically for black, indigenous, and other individuals of color. Another status the Contraceptive Mandate does not adequately address is economic status. It is easy to assume that because the Contraceptive Mandate includes requirements for no-cost sharing for the patient that economic inequality would not be an area where it comes up short. However, the insurance gaps that were created by the ACA and Contraceptive Mandate serve as glaring highlights to that effect. As states by Participant 2:

We have done, I think, a bunch of really good and impactful things in the community mostly overcoming barriers to contraceptive access. In all my [work]…it was baffling to me that we made it absolutely hardest for the people with the fewest resources to be able to time their pregnancy.

The Contraceptive Mandate did see marked improvement in expanding access to individuals who were already fairly well-off economically (Stidham et al., 2014). However, it did not serve lower economic status individuals equally. The Contraceptive Mandate applies to only private employers’ insurance plans and its allowable exceptions have broadened. These aspects of the law have led to many women who do not have available resources on hand, like time or even a car to get to a clinic during operating hours, to find themselves unable to utilize their preferred methods of contraceptive care. Participant 3 hopes “to see some more of redistributing power and resources so that we don’t have these health disparities, keeping our communities sick, marginalized, and literally in toxic areas as the only places to live.”

The Future of the Contraceptive Mandate

As in any legislation, the Supreme Court can play a large role in policy decisions. Since Donald Trump announced his candidacy for president in 2015, it has been no secret that he hoped to dismantle the ACA. However, President Trump and Congressional Republicans have never summoned the votes to repeal the measure totally, even when in control of Congress and the White House. The Supreme Court has also made it clear that the court is not willing to do the work for them (Barnes et al., 2020). With the recent announcement of a new presidency, there is hope that the ACA will not only stay intact, but be built upon to improve the lives of individuals throughout the United States.

As we discussed the future of the ACA with the three interviewees, all noted that the future of the ACA was dependent on the 2020 election outcome and the Supreme Court case, California v. Texas (2019). While the interviews were held prior to the 2020 election, the hope of the interviewees was clear as the future of the ACA and its Contraceptive Mandate was discussed. It should be noted, however, that all interviewees did express the importance of changes that needed to be made even if a new president was elected. Participant 1 noted:

If Joe Biden wins and we have, for some reason, the House and the Senate, I would expect that they would take steps to change the ACA and codify even further. One of those steps could be encoding the Contraceptive Mandate more firmly into the ACA, specifically with wording. Whether or not that would subsequently stand up to a Supreme Court challenge with a conservative court would remain to be seen. I think that so much depends on what happens right now. I think that if we continue to have the type of administration that we have, we will continue to see holes and gaps in care. But even if we have an administration change and some of those gaps are covered, that doesn’t remove the fact that the ACA still isn’t applied uniformly across the country. We still have those gaps in coverage.

Given the nature of their jobs and backgrounds, each interviewee expressed hope and changes for the future of the Contraceptive Mandate. While each response was different, all expressed their hopes that the Mandate would be improved upon, but that people would start working together and agree that while their views may differ, their opinions are just as important. Participant 2 expressed his hopes for the Contraceptive Mandate and the ideal way individuals should go about working with one another:

You know there is this absolutely beautiful framework that tells us exactly what to do and it is called Reproductive Justice…It is a human rights approach to providing access and care for people who have the ability to reproduce. It was founded in 1994 by 12 African American women and what they said was that there are [essentially] three tenants of this and a whole bunch of criteria around it. But the three tenants are…Everyone has the human right to first have a child, not have a child, and parent their children in a safe and healthy environment. And more recently a fourth thing has been added which is to enjoy and express themselves sexually as is pleasurable to them. So, if we can just take a deep breath and agree on that and say my views may differ from yours, but I understand that freedom means the ability to choose anything that is safe and reasonable.

Participant 1 also expressed her hopes for the future of the Contraceptive Mandate in the form of four key components that she believed truly could make a difference to those seeking help and various contraceptive methods through the ACA:

So, we need more methods, we need better methods and we need better access to coverage of those methods. If I could see those three things, that would make my day, and then if you put a cherry on top of that day it would be that providers didn’t have biases and stopped seeing unintended pregnancy as a disease outcome. More counseling around person-centered decision-making and less around I’m going to help you avoid this disease. I would love to see that.

While the ACA’s Contraceptive Mandate is not perfect, it has allowed a framework to bring hope and help to individuals and families throughout the nation. As we interviewed three women’s health professionals, we learned that while there is still much to be desired from the Mandate, there are many accomplishments and successes that have come through it as well.

Discussion

Through our study, we learned many impacts that the ACA’s Contraceptive Mandate has had on women’s access to reproductive healthcare, both in positive and negative senses. We learned that many individuals now have the opportunity to receive contraceptive methods at little to no cost, affording people throughout the nation the opportunity to choose their bodily and reproductive health over financial burden. Not only do individuals have the opportunity to receive contraceptive methods at no-cost, but people now have the opportunity to choose from a plethora of method options to best suit their lifestyle.

As has been discussed, we know that not all methods are appropriate for all people at certain times in their lives. Through the ACA’s Contraceptive Mandate, people are now provided the opportunity to use a method that is correct for them at any given time in their life. As stated in the literature review, quality of life has been shown to improve with access to reproductive care. Women who are in control of their bodies are able to fulfill their aspirations and contribute to society in different ways, by creating societal and economic impacts in ways that may not have been possible without access to needed contraceptive methods.

The Contraceptive Mandate has also provided the ability to help policymakers, healthcare professions, and individuals across the nation realize that women’s healthcare is an essential part of primary healthcare. Prior to the ACA, there was a great divide between women’s healthcare and primary care causing a split in insurance coverage, primary care practices, and more. While the Contraceptive Mandate has not fully solved that divide, all interviewees pointed out how the Mandate has helped to open the eyes of individuals and create a new norm for women’s healthcare in primary care. We acknowledge that while there have been many benefits and steps of progression given to women’s reproductive healthcare due to the Contraceptive Mandate, we know that there are still many problems yet to be solved.

For example, women are hindered from having the best access to reproductive care because of the expansion of the religious exemption. It is a matter of imposition of religion over women’s choice. Yes, religion should have protection from government interference (DeBoer, 2015). However, the extent of its overarching power when it comes to women’s reproductive health should be controlled if women are to have equitable access. This hurdle is by far the biggest that women face today, especially those who are covered by a religious organization’s health plan.

Additionally, inconsistent implementation of the Mandate coupled with inconsistent application of other components of the ACA, such as Medicaid Expansion, make it difficult for all women to receive quality reproductive care. Similarly, the insurance coverage gap limits the number of women who can receive the contraceptive method of their choice. Individuals should possess the ability to select the method with the least number of complications for them; to choose a method that helps them lead lives that are more enjoyable. Given that, it appears that the Mandate has not sufficiently addressed these issues and fails to give enough power to women so that they are equal players to men in the outcomes of their reproductive health.

The Contraceptive Mandate should not be viewed as a cure-all for the many disparities that persist across women’s reproductive healthcare. Compared to our standard (DeBoer, 2015; MacCallum-Bridges & Margerison, 2020; Tschann & Soon, 2015), the Mandate has not fully met goals such as reducing women’s health disparities and equalizing women’s status as healthy and productive workers. Based on our interviews, there is no denial that the Mandate benefited many women. However, like most governmental policies, much more work is needed. Barriers to equitable and quality reproductive care continue to exist. Ideally, women should have a choice in how to take care of their bodies. Unfortunately, religious views, inconsistent and overcomplicated implementation of the Mandate, and insurance coverage gaps make it difficult for women to have a say. Women deserve to play a more active role and decide for themselves which contraceptive methods work best for them. Money should not prevent women from receiving quality care. Moreover, intersectionality has not been addressed sufficiently by the Contraceptive Mandate. The systems currently in place have moved in the right direction, but more remains to be done.

Study Limitations

Study limitations are a very real part in any research study, no matter the topic, research design, or sampling method. It is imperative that researchers should do what they can to limit errors and be honest about their methods (Johnson, 2015). Through reporting possible study limitations, we strive to give readers the opportunity to understand our research and give readers the information they need to arrive at notable conclusions. We also know that by stating our study limitations, we have the opportunity to make suggestions for further research.

Our first noteworthy limitation is one of time. While the project was designed to be executed in a short time period, it is worth emphasizing that we had a small window of opportunity to perform an analysis, interview women’s healthcare professionals, and find existing and relevant data to our topic. We know that we were limited in our ability to find all relevant data to contribute to our conclusion, however, we narrowed our topic to fit within our window of time.

Our second limitation stems from our selection of healthcare professionals to understand the scope of the Contraceptive Mandate’s effect on women’s healthcare. We acknowledge that by interviewing three professionals, we are left with a small sample size that may not be representative of the population as a whole or all of the views of the effects of the Contraceptive Mandate. Because this study’s sample size is small and local, its overall reliability is quite limited. However, limited generalizability does not negate the value of interviewee responses, questions, and time with interviewees to serve as a barrier to our perspectives and lack of knowledge.

In addition to a small sample, we must note the substantial similarities shared by the respondents. Two of our interviewees worked for the same family planning organization, while the third worked for a separate family planning organization. The interviewees also shared similar (progressive) political ideologies. These similarities (among others) leave open the opportunity for further research to explore the effects of the Contraceptive Mandate from different viewpoints and political affiliations.

We acknowledge that much of our project is centered around our interpretation of documents, other research, interviews, and more. We know that there were biases represented in our collection of data, but we strived to serve as checks and balances to each other throughout our research process. While biases may exist in our research, our research can serve as a foundation for additional research in the future.

We acknowledge that, as researchers, we all have an interest and recognition of positionality towards access to women’s healthcare. We believe that women should have the ability to access and afford healthcare no matter their state or situation. As we proceeded with our study, we recognized that we needed to set aside our personal and political preferences to better understand how the Contraceptive Mandate impacted access to women’s healthcare so that we could accurately report on what we found through analysis, interviews, and more. In turn, our perspectives may have helped us find information that is not readily available as well as connect on a more personal level with interviewees.

Conclusion

Our study of the ACA’s Contraceptive Mandate and its effects on women’s reproductive healthcare has led us to find that the Mandate has helped progress women’s healthcare in great strides. The Mandate’s benefits of no-cost contraceptives, the coverage of various contraceptive methods, and a change in healthcare perception has helped shape the nation’s society throughout the past ten years. More women have been afforded the opportunity to choose health and safety over fear and financial burdens, which has helped bring about a stronger community and greater understanding. While the Contraceptive Mandate has helped to improve women’s reproductive healthcare, we have found that there are still many gaps needing to be addressed after a decade of policy implementation.

Through our interviews and additional research, we know and understand that the Mandate still needs to provide better implementation processes and coverage of various insurance gaps. Through the limited time and resources available to us, we understand that our study gives readers only a small snippet of a much larger and complex issue. As researchers aim to learn more about the ACA, the Contraceptive Mandate, and women’s reproductive healthcare, we encourage individuals to look deeper into the consequences of the Mandate for various races, genders, and those of different economic statuses. It is also recommended that studies on this topic should focus on the Mandate’s effects on those who may identify as female, but who were not included in our given definition of women, or who are considered female, but may not identify as such. Through creating future research and studies on various aspects of intersectionality on this given topic, we look forward to the day where our hopes for women’s reproductive healthcare can be achieved and individuals are able to have the resources given to them to make the difference needed to change a nation.

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Appendix 2

Interview Questions

Background:

  • Tell me about your path to this current role within your organization. What is your background and what interested you in the women’s healthcare field?
  • Can you describe the population of women you serve and explain your role’s relationship with helping those women access reproductive care?
  • How does your organization and how does your role, specifically, advocate for women’s improved access to reproductive care? What actions are you and/or your organization taking to improve access to reproductive care for women?

Understanding of the ACA Contraceptive Mandate:

  • Are you familiar with the Affordable Care Act’s Contraceptive Mandate? Tell me about your understanding of it.
  • What do you understand the purpose of the Contraceptive Mandate to be? Do you believe it has fulfilled that purpose? Why or why not?
  • How do you help fulfill the requirements of women’s reproductive care in the Contraceptive Mandate?

Implications of the Contraceptive Mandate:

  • As you understand it, tell me about any structures, administrative, social, internal, or otherwise, that were created by the Contraceptive Mandate?
  • As you perceive it, what benefits were created by the Contraceptive Mandate with regards to women’s access to reproductive healthcare?
  • As you perceive it, what challenges have been presented by the ACA’s Contraceptive Mandate with regards to women’s access to reproductive care?
  • How has your organization and your role within the organization changed since the implementation of the Contraceptive Mandate?
  • What are the religious, economic, and social implications of the Contraceptive Mandate?
  • How does women’s access to reproductive care change across different populations (such as race or educational attainment)?
  • How does expanding contraceptive access impact women’s overall reproductive care? How has it impacted your ability to help women gain access to reproductive care?

Looking to the Future:

  • What changes do you predict will be implemented in women’s reproductive health services at your organization since the decision reached in Little Sisters of the Poor v. Pennsylvania? (See this link for more information: https://www.scotusblog.com/2020/07/ opinion-analysis-court-rejects-challenge-to-exemptions-from-birth-control-mandate/)
  • What do you foresee as the future of the ACA’s Contraceptive Mandate within the next 10 years?
  • What would you like to see happen in women’s access to reproductive care? Why?

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Inquiry of the Public Sort by Shykell Ledford; Kristen VanLeeuwen; and Logan Waechtler is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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