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How Insurance Affects Birth Control Choices: One Woman's Story

by Kaylen Ralph
December 20, 2016 | Our Future

Here’s a free recipe for an effortless humble pie this holiday season:

1. Decide to write a personal essay/objective investigation of the current female contraceptive landscape. Add in a healthy dosage of contemplation about getting an IUD before Jan. 20, 2017.

2. As you reflect on your contraceptive history, call up your ex-boyfriend from college whom you dated more than five years ago, to ask him about how he thinks you responded to “the pill” as a 20-year-old.

3. Encourage him to be honest in this reflection.

4. Eat it.

Sunday, Nov. 20, 5:52 p.m.

“Hey, this is an odd request you can totally decline, but I’m working on an article…about birth control, specifically ‘the pill.’ It’s still the leading contraceptive option used by women ages 15 to 44. I don’t know if you remember, but I went on the pill *after* we started dating in college. The piece I’m writing is from my personal perspective but grounded in contemporary research and events.”

Though he certainly didn’t have to, Patrick agreed to chat (either before or after his soccer game).

birth control

Maybe you’re wondering why I thought that reaching out to my college boyfriend was a necessary element to include in this article. I was inspired to explore the topic of prescription birth control, “the pill” in particular, after a recent visit to my doctor, where she asked me seemingly simple questions about my birth control prescription history (Why I had been taking a certain pill for the past two years, whether I had exhibited any symptoms or side affects that would necessitate a change from a “combination” to “minipill” two years prior—I didn’t know the difference, let alone the reasoning). My lack of knowledge for my own reproductive history was eye-opening.

Why I started taking the pill

A little about me. I’m a Minneapolis transplant of three years by way of Columbia, Missouri, where I lived for four years while attending the University of Missouri School of Journalism.

Since meeting Patrick and deciding to go on “the pill” in late 2010/early 2011, I’ve seen three different general and/or nurse practitioners, not counting the doctors that were provided by my university’s healthcare system. It was not my intention to bounce around so frequently, if an average of one new doctor every two years can even be described as “bouncing.” I went home to Illinois for winter break in the late winter of 2010 as a college sophomore. By the time I returned to school one year later, I was a proud pill-popping cohort of the reproductively liberated women I had grown up aspiring to be.

That’s the extent of my memory of the decision to start a continuous dosage of medications that would come to define more than half of my twenties. Flying home from school, telling Mom about Patrick and how I “needed the pill.” I’m proud of the take-charge approach I took to launching my sexual career: I wanted to have sex, I didn’t want to be pregnant. To my mom’s credit, she asked me whether I was interested in exploring other options, or perhaps waiting it out a bit to see what happened in my relationship. I was completely disinterested and demanded a meeting with her gynecologist right away. My enthusiasm about getting my new prescription filled and my anticipation of how grown-up I would feel rolling back to Missouri with a new sheath of pills in my purse outweighed these very understandable and retroactively appreciated concerns of my mom (sorry, Mom).

The only constant is change

In October of this year, when I met with my new doctor in Minneapolis, she switched me from the progesterone-only minipill (Nora-BE) that I had been on for almost two years to a combination pill (Lutera), which she said would help me manage monthly bouts of anxious inactivity and depressive thoughts. This switch occurred only after she asked me whether I might be interested in an IUD or implant. She said I was a prime candidate for an IUD or implant, due to my fraught history with the pill and my inability to consistently take it at the same time each day, an critical thing to do when you're on oral contraceptives.

Until I heard myself respond with immediate protest, I didn’t realize what a strong opinion I had cultivated regarding the IUD and its equally intravenous long-acting reproductive contraceptive alternatives.

But when the election happened, it seemed the million dollar question—at least at my workplace among my female coworkers—was “Are you thinking of getting the IUD before Jan. 20?”

We tried to help each other dissect our respective insurance plans, figure out which doctors were in-network and brainstorm who in our cohort had a referral for a doctor they liked and might be able to squeeze in a buddy in case the new administration repealed the Affordable Care Act (as he had repeatedly promised to do during his campaign) before we were all left with uncertain monthly prescription costs and no other options until a potential regime change in 2020.

After work that day, I called my current boyfriend, Frank, and for the second night in a row, I cried myself to sleep. This night, I was fresh from a hard day at work with a lot of young women who felt the same post-election panic that I did. I cried under the dark cloud of a reproductive healthcare system that, to date, is still uncertain, with the weight of my own reproductive future on my shoulders.

A popular, imperfect choice

In my conversation with my ex, Patrick, the tidbit he shared with me about our time together (a brief year and a half that, in hindsight, was largely defined by my attempt to adjust to my new prescriptions), what struck me the most was his acceptance and acknowledgement of my need for utter and complete control. It was the first thing he brought up when I asked him whether he was surprised by the weight gain or mood swings brought on by my use of the pill six years prior, almost to the date.

“You just really liked feeling like you were in control of things,” he said over the phone. “It’s why you never did any drugs. You really liked to be in control and feel like you were in control all the time. I can see how if then, all of the sudden, you’re starting to take this pill that is making your emotions go out of control, then that would really bother you. It would really bother me.”

The same personal attributes that make me a good manager and creative entrepreneur are the same attributes that disqualify me as a prime candidate for the pill, though I’ve continued using it for the past six years. I don’t maintain a particularly regular routine and therefore am usually taking the pill earlier or later than I should; sometimes I pop a few at once and chase it down with a glass of wine, or a kale smoothie, depending on the time of day that I realize I’m a few punctured tabs behind. I’m completely aware that taking the pill with anything less than military precision is not ideal, but, c’mon, isn’t that a little unrealistic? I can’t be the only one who misses a pill here and there, or wakes up in the middle of the night with a jolt realizing I’ve drifted off without doping up. I know that all of the above makes me a prime candidate for an IUD, and I might be interested in exploring the option of it, but I’d prefer to do that on my own time, in my own way.

According to a July 2015 report by Laurie Sobel, Adara Beamesderfer and Alina Salganicoff for the Kaiser Family Foundation, the most common method of contraception among women ages 15 through 44 is the pill (26.7 percent), followed by female sterilization (25.1 percent) and male condoms (22.8 percent).

And, according to a September 2016 “Contraceptive Use in the United States” report by the Guttmacher Institute, “the pill and female sterilization have been the two most commonly used methods since 1982. Four of every five sexually experienced women have used the pill. The pill is the method most widely used by white women, women in their teens and 20s, never-married and cohabitating women, childless women and college graduates.”

It’s important to note that when you narrow the age range from 15 to 44 down to 25 to 44, the above statistic looks very different. As Planned Parenthood reported in February 2015, “IUDs and implants now represent the third most commonly used category of reversible contraceptives among women ages 25-44, after the pill (19 percent) and condom (13 percent).”

birth control
Over time, use of long-acting reversible contraceptives, including IUDs, has increased, especially among women ages 25 to 34. The colors in the key are representative of age ranges. Source: Centers for Disease Control and Prevention.

Either way you cut the pie (chart), there are still a lot of women relying on the pill as their preferred form of birth control.

Wednesday, Nov. 9, 4:35 p.m.

I told Frank that I was seriously considering the IUD for myself.

“That’s kind of a big decision.”

“I know.”


Initially, the thought of regaining control over the uncertainty of the most recent election by means of arming myself with a T-shaped uteral weapon felt really good. (Like, really good. I won’t lie.)

birth control

But I realized something—the Affordable Care Act, which passed in 2012, legally protects a woman’s right to adopt any contraceptive method she likes without any out-of-pocket cost. And yes, until Jan. 20, 2017 at least, that right is still protected by law. It is also a right that is unlikely (read: impossible) to go anywhere for the next year, even if the new administration decides to repeal the portion of the ACA that protects a majority of women’s zero-cost access to the contraceptive of their choice.

Before the ACA was enacted, my relationship with the birth control pill was nerve-wracking. I remember the months where I proudly went to the Walgreens one block from my college-town apartment to purchase a prescription that changed often, sometimes because I asked, and sometimes because a generic option became more available (with a great price break for me). The panic-influenced decision process, which I and my friends participated in without protest, is troubling because it strips the choice we’ve fought for (and by we, I mean generations of women before me).

Personally, the knee-jerk reaction of “go out and get an IUD ASAP” feels like a slap in the face to the six years of work I have put into learning who I am as a controlling, sure, but intensely ambitious woman who takes the pill to prevent unwanted pregnancy, both within the context of relationships with partners I’ve loved and men I have not. There never has been, nor ever will be, a “one-size-fits-all” response to the question of contraceptive, so why are we responding now as if there is?

The narratives I found missing in the countless articles that have been released about the need for IUDs right now are those that speak to the unquantifiable number of women who have already tried the IUD, or would like to, but can’t.

“I got my IUD (Skyla) removed after a year about six weeks ago because my symptoms were miserable,” said Megan, 26, a friend of mine from college. “(I) gained an unbudging 5-10 (pounds) almost immediately, cystic acne (after having generally good skin the rest of my life), my last period lasted for about a month and was always irregular with IUD, and other misc. issues. I think my uterus just did not appreciate having a piece of plastic in it.”

Sheela, 26, another woman I went to college with, felt inspired enough by the post-election rhetoric to at least explore the option of an IUD, despite never wanting one before.

“I have ovarian cysts so for me, an IUD wouldn’t give the hormonal doses I need to keep the cysts at bay; I would have to couple it with pill. I will need to stay on the pill until I decide to get pregnant for the hormone doses,” she said. “The (post-election) hype around it led me to talk to my mom (a physician who had an IUD for 15 years) and it just didn’t make sense for me. My medical condition ensures I’ll have access to (over-the-counter prescriptions).”

“Among contraceptive users, the groups of women who most commonly use IUDs and implants are those aged 25-34,” but the younger cohorts of these women (ages 15 to 24), are the ones most likely to forgo hormonal birth control all together, in favor of “the pullout method,” or male condoms, the usage of which have “increased from 52 percent in 1982 to 93 percent in 2006-2010.”

birth control

There is a real aversion to hormonal birth control bubbling amongst the demographic that feels most mobilized in light of the election, the same demographic who will likely shape the outcome of the next election in four years. It’s true that IUDs are the best option as far as reducing the number of synthetic hormones your body is absorbing on the reg. The hormones in IUDs are localized to the uterus, releasing only one tenth of the progesterone that most pills do. But just as the pill isn’t perfect, neither is any option currently on the market today.

Getting the perfect cocktail of progesterone and estrogen just right in my pill(s) is the reason why I’m still in hot pursuit of the one that works perfectly for me, though I’m starting to doubt that such a pill exists. I remember my initial foray into the world of prescription birth control as a hazy den of out-control-hormones, but chatting with Patrick gave me a new perspective that feels relevant now. Whereas what I remember is rapid weight gain and vague, occasional mood swings, he remembers me losing interest in the things that I had loved before going on the pill, “kind of what happens when people get depressed,” he said. He said I began hating my job at the student newspaper, for one. I never had the energy to work out, despite becoming obsessed with weight gain I couldn’t justify. Both are things that I have since found interest in again (though I’m no longer working for an on-campus newspaper). But I’m unsure what of that can be attributed to my emotional maturation, and what I can attribute to the pill “messing” with me.

“I know that just being on the pill in the first place was probably, especially for someone having to go from (being) a normal, healthy person, and then you have to go to taking a prescription drug everyday, I think (that) is an adjustment,” Patrick said.

Friday, Nov. 11, 8:15 a.m.

At 26 years old, I feel more assured of the woman I am than the girl I was at 20, and I know that, even on the days where my entire existence feels heavy under the weight of synthetic hormonal smog, I can still reach deep into my belly and grab tightly the pieces that are unequivocally and unapologetically me. I have been doing that a lot lately, and I attempt to secure not just my footing, but my thoughts and my voice.

All things considered, the implication that this is a decision we have to make alone, or in a panic, emboldened only by the advice of “the media,” (of which I am a proud member) is as equally demeaning to me. I didn't document my experience of going on the pill, but Patrick's recollection of the time shocked me. There were the sudden mood swings and emotional outbursts we both remember, some of us better than others, but he had clear memory of my proactive attempts to change prescriptions when my body or my mind didn’t feel right. I felt alone during that time, underestimating the extent to which he felt personally implicated in my reproductive health. Patrick’s memory of my physical and emotional state at the time I started taking birth control gives me a lot of peace, though it doesn’t make the decision to forgo the years of “work” I’ve put into mastering the pill, if I can even say that I’ve mastered it at all, any easier.

Final decision? I'm going to stick with what works for me—the birth control pill. But it's not going to be the same journey I was on before.

If anything, I am more emboldened to ask more questions, to take more notes, maybe even keep a daily log of how I feel each day of my cycle. I feel better arming myself with all the facts, including the facts of my own history, rather than an entirely new device that isn’t necessarily any better for me or my body.

Kaylen Ralph
Kaylen Ralph is the co-founder, editorial development director and brand director of The Riveter Magazine, a longform women's lifestyle magazine in print and online. She works as a personal stylist for Anthropologie. Follow her on Instagram @kaylenralph for books and fashion. You can also find her on Twitter at @kaylenralph.
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