Re: Testimony in Support of LB 20
Dear Chairperson Williams and members of the Committee,
My name is Meg Mikolajczyk and I am the Deputy Director and Legal Counsel for Planned Parenthood North Central States in Nebraska. Nebraska is home to two Planned Parenthood health centers, located in Lincoln and Omaha. We also deliver limited care via our app, PP Direct.
Annually, we provide care to over 9000 unique patients, with about 37 percent of our practice dedicated to prescribing and providing birth control to patients.1 Birth control methods that are the subject of this bill—oral contraception, the contraceptive patch, and the ring—make up about 19 percent of all visits and half of the birth control methods prescribed. Currently, we prescribe a 12-month supply, but our patients are limited in their access to that supply by insurance. While some patients can receive a three-month supply, the majority are only getting one month supply at a time.
In 2020, our Omaha health center had 2,618 visits for supply pick up or delivery and the Lincoln health center had an additional 2,063 visits for pick up or delivery.2 Thousands of Planned Parenthood patients, and tens of thousands of other Nebraskans, would greatly benefit from the passage of LB 20, which tears down many barriers to accessing and consistent use of prescription birth control.
Studies show that when patients do not receive a one-year supply of the birth control method of their choice, one in three patients will fail to refill their prescription, which increases the likelihood of an unintended pregnancy. This in turn leads to increased costs to insurers, including Medicaid, for those unplanned births.3 The risks created by the unnecessary barriers erected by insurance companies—increased likelihood of discontinued or inconsistent use—is greater than any risks associated with prescription hormonal birth control methods.
Doctors agree with this position—it is standard practice to prescribe an annual supply at the time of visit once a patient is counseled in available methods, a complete medical history is taken, anticipated side effects are discussed, and sufficient education is provided regarding both use and when to seek medical assistance. In fact, ACOG, the experts in sexual and reproductive health, believe these risks—irregular bleeding, headaches, potential weight gain, and in rare events blood clots—are so minimal that these methods should actually be available over the counter.4 And, again, many of these risks can be further mitigated during the consultation that occurs between patient and prescriber at the initial visit and annual appointments thereafter.
Relatedly, some opponents may claim patients should have a follow up appointment with their physician one month after starting the prescription. First, that is not standard medical practice for prescribing hormonal birth control and second, nothing in this bill precludes that follow up appointment from happening in instances where the patient and/or provider feel it is necessary. Nothing in this bill requires a physician prescribe for all 12 months, and this bill does not regulate physicians’ ability to prescribe at all; this is simply about whether insurance should cover the amount of the supply that a physician, using their medical judgment, deems is appropriate for their patient.
Birth control is not like other prescription drugs, and therefore, should not be covered or constrained in the same way. It is true that some reasons insurance companies limit availability of supply include dosage inconsistencies, risk of gap in supply being detrimental to overall health, and risk of abuse. Consider, for example, the interest of a physician or insurance industry in limiting available supply of opioids—the patient’s dosage will likely need to be changed and adjusted with regularity, the risk of missing one pain pill is not life threatening, and the risk of abuse is high. Birth control medication dosage is generally static, the risk of abuse is nominal/unknown, but, and here is the important thing, the risk of missing one pill is life altering. One missed dose can result in an unintended pregnancy.
Another critique of this policy could be the idea that giving a 12-month supply of medication to people will result in undue expense and waste to insurance companies—in other words, women will be fickle with their birth control method, receive their 12-month supply and in, say, month six, they change to a different method, which the company will also have to cover. Importantly, six months of birth control pills, rings, or patches not used is nothing in cost compared to the unintended pregnancy that may result from not having access to these medications. And, this concern is largely theoretical. In one study, only 12 percent of women receiving a one-year supply actually changed their method over the course of the year.5
Finally, some folks indicate a concern about safe long-term storage of these medications. Oral contraception and the patch should be stored similarly, at room temperature away from extreme moisture or humidity. The ring must be kept under certain temperatures; the easiest way to store it is in the refrigerator. Coincidentally, these same temperature and moisture rules apply to a myriad of over-the-counter medications that people possess and use for longer than one- or three-month intervals.
For what it is worth, condoms, the main method of male birth control, need to be kept in cool, dry locations and not be exposed to friction; failure to comply with these storage methods may result in method failure. There is no limit on the number of condoms a person can purchase or have in their possession despite storage risks, and often this less effective method will be used when a gap in prescription supply occurs. This noted concern about safety and efficacy of use seems less rooted in data and more based upon problematic gender stereotypes about women being unable to take care of their own health and bodies.
Prescription birth control is safe. It is already being prescribed for 12 months at a time with regularity. Lack of insurance coverage is the only reason women cannot currently have their entire supply at once. We know that when people do have their full year supply, they are more successful in consistent usage and preventing pregnancy. For these reasons, we respectfully request the committee advance LB 20 to general file. Thank you, Senator Blood, for working to ensure equitable and consistent access to birth control for Nebraskans.
Deputy Director - NE
1 “Average Percent of Visits over 12 months (Jan – Jan); Trends from PPNCS COO Report”, as of January 2021.
2 “Clinical & Supply Visits, Northwest and Lincoln South Health Center”, Planned Parenthood North Central States, PPH Practice, printed 25 Feb 2021.
3 Fan, PhD., Z. Joyce, et al, “The Effect of Dispensing One-Year Supply of Oral Contraceptive Pills; Findings from Washington State”, Washington State Department of Social & Health Services, pp. 1, 4. Nov 2018.
4 “Over-the-Counter Access to Hormonal Contraception”, American College of Obstetricians and Gynecologists, Committee Opinion No. 788, Oct 2019. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/10/over-the-counter-access-to-hormonal-contraception
5 Fan, PhD., Z. Joyce, et al, “The Effect of Dispensing One-Year Supply of Oral Contraceptive Pills; Findings from Washington State”, Washington State Department of Social & Health Services, pp. 1, 4. Nov 2018.