Jonathan Cohn

No, You Can't Always Get Birth Control Pills for $9

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Here’s one thing the controversy over health insurance and contraception has taught us: Conservative men need to learn a thing or two about reproductive health.

Right-wing radio host Rush Limbaugh made this obvious when, echoing other some other conservatives, he suggested women wouldn’t need coverage for birth control if they didn’t insist upon having so much sex. Referring to Sandra Fluke, the Georgetown law student who has advocated for such coverage, Limbaugh said, “She wants to be paid to have sex. She’s having so much sex she can’t afford the contraception. She wants you and me and the taxpayers to pay her to have sex.”

As you've read or heard by now, Limbaugh misrepresented Fluke’s testimony: When Fluke spoke on Capitol Hill, she described the plight of a classmate who needed, but could not afford, birth control medication to treat ovarian cysts. But somewhere in between mangling Fluke’s story and calling her a “slut,” Limbaugh also betrayed some medical ignorance.

Birth control pills aren’t like Viagra: You don’t just pop one whenever you want to have sex. Women must take them continuously, typically once a day, over the course of their menstrual cycles. That’s true whether they have sex once a day or once a month. (Rachel Maddow covered this, along with some other relevant issues, in a very helpful segment last week.)

Alas, the dosage of birth control is not the only misconception floating around on the right. Another is that just about everybody can already get effective contraception at low prices. John McCormack of the Weekly Standard figured that out by visiting the local Target and discovering that generic birth control is available for as little as $9 a month. "It strains credulity to believe that a single Georgetown student can't afford $9 per month for birth control," McCormack wrote.

I can't speak to the details of Fluke's testimony, but McCormack is telling the truth about what he found at Target. Most of the big pharmacy chains now offer some cheap generic drugs, even for people without insurance. For women who take those particular drugs, it’s a genuinely good deal.

The problem, as doctors and pharmacists will tell you, is that not every drug works for every woman.

Oral contraceptives can cause side effects, including nausea, bloating, weight gain, and headaches after initial dosages. They are less effective in patients taking other medications (like anti-convulsants, which physicians use to treat a variety of neurological and psychiatric conditions) and they can aggravate existing medical conditions (like migraine headaches or high blood pressure). Birth control pills that contain estrogen can actually be life-threatening for women with histories of blood clots and some cancers.

The pills with estrogen are also a problem for women who are breastfeeding. “Women that are nursing their babies can't take them because the estrogen can decrease milk production or dry the milk completely,” Cristina Rojas, a pharmacist who happens to be my neighbor, explained to me on Sunday. Making the right contraceptive available to new mothers is a big deal, by the way, because spacing pregnancies apart has serious medical, as well as socio-economic, benefits. (Although breast-feeding reduces the chance that a woman will get pregnant, it does not eliminate the possibility altogether.)

For some women, finding the right contraceptive is a matter of finding the right pill. For others, it’s a matter of finding a whole other birth control method – like implants, inter-uterine devices, or surgical sterilization. Most of these alternatives cost more than $9 a month and some of them cost a lot more than $9 a month. But plenty of women still need them, according to Caren Stalburg, an assistant professor of obstetrics and gynecology at the University of Michigan:

The decision for which dosing schedule, hormonal composition, and/or delivery device depends on a variety of factors including patient choice, ease of use, the patient’s medical history, how quickly the woman would like to resume her ability to conceive, etc. Adding to the complexity, sometimes these medications and devices are utilized for non-contraceptive indications such as abnormal bleeding, endometriosis, pelvic pain, management of acne, treatment after pregnancy losses due to molar pregnancies, and sometimes even in conjunction with assisted reproduction technologies. 

Melissa Gilliam, a professor of obstetrics and gynecology at the University of Chicago, brings up another reason why women might seek out alternatives to pills, generic or otherwise: There's no danger of forgetting to take them.

People are very poor at adhering to daily medications and birth control pills are no different. In some studies almost half of young women have stopped taking birth control pills within three months. Adherence and continuation rates are much higher for long acting methods such as the intrauterine device. Regardless, women will do best with the method they want to use.

Adam Sonfield, senior policy associate at the Guttmacher Institute, sums it up well:

It's great when low-cost generics are available, if one of the ones available is the right method for you. But if we were talking about medication to address high blood pressure or to treat cancer, no one would take seriously this type of argument: "You don't need insurance coverage for that medication your doctor recommends. See, there's a different drug on sale at Target. I'm not a doctor, but, hey, it's probably just as good for you."

To be clear, McCormack and other conservatives make additional claims. They suggest, for example, that health insurance simply shouldn’t cover so many routine medical expenses – or that the public interest in providing such coverage shouldn’t outweigh the public interest in respecting the wishes of religious leaders.

I don’t agree with either one of those arguments, but that's largely a matter of philosophy and judgment. The availability $9 birth control pills is a matter of substance.

follow me on twitter @CitizenCohn

Update: I made a few revisions, adding a quote from one authority (Dr. Gilliam) and making clear that I am not in a position to verify the details of Fluke's testimony. Personal stories are frequently more complicated than they seem, even to people in the middle of them.

Update 2: I'm not sure how I missed it, but last month Mother Jones published a calculator for birth control costs. Among the sources it cited was a report, from the Center for American Progress, on the same subject. Both are worth checking out. Meantime, here is a helpful chart from the CAP report:

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