For two years, Megan Danna ’08 had been dutifully swallowing her birth control pill at the same time every day. The daily dose of estrogen and progestin in Ortho Tri-Cyclen Lo helped keep her severe premenstrual symptoms at bay. Even better, it was dirt cheap. She remembers paying as little as four to eight dollars for four months worth of her pill of choice when her prescription began.
Then October rolled around, and the price jumped. Instead of a few odd dollars, Danna found that she would have to pay 52 dollars a month to keep her prescription.
Previously, Danna had not been able to justify getting her favorite pill (Lessina) while a cheaper option was available. Now that Ortho Tri-Cyclen Lo was so expensive, however, she was ready to make the change, and so made an appointment with her gynecologist. Danna’s reaction to the price hike is common among Yale women, who are covered by their parents’ insurance and with free cash to spend. Maybe they go to a new pill. Maybe they just pay more. But almost none find themselves forced off birth control.
According to the American College Health Association (ACHA) National College Health Assessment from Fall 2006, nearly 38% of undergraduate women use birth control pills. Since January, women across America have trekked to university clinics to pick up their hormonal birth control only to find that recent legislation caused the price to increase — drastically. Paula Tran, a senior at the University of Wisconsin-Madison, told Time magazine that the price of her pill is now five times the original amount and that the price change would affect her future spending on items ranging from notebooks to groceries to cable TV. Malia Mason, a sophomore at the University of Pittsburgh, told U.S. News & World Report in October that she would have to spend 360 dollars more per year to keep her prescription, as much as her annual electric bill. She did not yet know what she would do, but added that some of her friends could no longer afford the pill and had stopped taking it. At Bowdoin College in Maine, women don’t even have the luxury of making the decision: the price increase caused the health center to stop carrying the pill.
Students have not been silent about their outrage. According to the Report, students at the University of New Mexico and other schools nationwide have organized call-ins to their legislators to complain and urge action. ACHA has also lent its voice to the cause. Mary Hoban, the association’s advocacy chair, told Time that members of ACHA were calling Congress to push for college clinics to be exempt from the law that caused the price increase.
Yale’s activist community has reacted in a similar way. On October 18, the Reproductive Rights Action League at Yale (RALY) organized a phone-a-thon event at Beinecke Plaza to call student attention to the price increase, as well as to encourage students to call the offices of Senator Christopher Dodd (D-CT) and U.S. Congresswoman Rosa DeLauro in protest. Debate about the role of the university in funding birth control raged in the Opinion pages of the Yale Daily News. And concerned women have voiced their support for proposed legislation that would return college health centers to the list of “safety-net providers”: institutions for which federal law requires drug companies to provide discounts.
But there’s a crucial difference between Yale and the rest of the country. For most women at Yale who are on the pill, monetary concerns are minimal. Most aren’t even taking the suddenly expensive Ortho Tri-Cyclen Lo, and many insist that price is not a significant factor in their decision to be on the pill. And many of these women, whose feminist mothers and grandmothers might have fought tooth and nail for the right to affordable birth control, don’t perceive serious threats to their reproductive rights — or even to their pocketbooks. Why do Yale women seem so unaffected by a price increase that is a catastrophe in the lives of college women across the nation? And why do even the protestors see no formidable threat to their right to contraceptives?
Sara Rahman ’09, a co-coordinator of RALY, was one of the women taking Ortho Tri-Cyclen Lo when the price rocketed in October. She was lucky enough to be able to absorb the cost. Having a job, she told me, allowed her to ride the price increase without any serious consequences. The people she worries about, she says, are those without jobs or not in college, since they can no longer procure cheaper birth control from a safety-net provider. Hers is one of the few argumentative voices on campus: “RALY’s standpoint is that reproductive health should not be a financial concern. It should be a personal concern.”
Jessica Hunter ’10 also became passionate about the issue. As a member of RALY, she was already interested in women’s reproductive liberties. When the price increase went into effect at Yale, she sent a concerned letter to the Yale Daily News detailing the disastrous effects the price increase could have on women’s health.
In her October 28 letter, Hunter pointed out the possible impact the price increase could have on the quality of student relationships, as well as on women’s ability to take care of their health. The picture she painted was bleak: “[The price increase] will alter the sexual relationships some women have with their partners, whether this results in less frequent engagement in sex or in the use of less reliable methods of contraception…If fewer women are able to buy birth control at their college health centers, fewer women will have cause to get yearly gynecological exams, which are essential to preventing and/or treating a slew of health problems, including STDs and cancers.”
Mary Hoban, the director of ACHA’s National College Health Assessment program office, agreed with Hunter’s claims, positing in a October 11 online article in the U.S. News & World Report that because obtaining birth control is no longer an incentive for some women to go to their health centers, fewer college women are receiving gynecological exams, screenings for sexually transmitted infections, and the HPV vaccine.
Health officials worry about unintended pregnancy. Hormonal birth control is one of the most effective forms of contraception, decreasing the chance of pregnancy to about .03%. Susan Yolen of Planned Parenthood of Connecticut has made a career out of providing reproductive health care to women in the neighborhood. She said, “College students are by and large at the time of their life when they are sexually active…We all know the more affordable [birth control] is, the more likely people are to use it.”
Dr. Nancy Jasper, an assistant clinical professor at Columbia University’s medical school, expressed similar concerns to Time magazine. “I think there are some who will just try to wing it and see how it goes,” she said. “They’ll say, ‘Well I go to school here, my boyfriend is in another city and I only see him once or twice a month and I won’t use anything,’ rather than pay.”
It’s all because of the Deficit Reduction Act of 2005 (DRA), which went into effect on January 1, 2007.
Contrary to rumor, the government’s regulations before the price change were not subsidizing hormonal birth control. In fact, no government money — and more importantly, no taxpayer money — was ever used to give college students cheaper birth control. The prices seen in college and university clinics were and are chosen freely by the pharmaceutical companies that market products like Ortho Tri-Cyclen Lo and the NuvaRing.
Mary Kahn, spokesperson for the Centers for Medicare and Medicaid Services (CMS), explained that once the DRA went into effect, college and university clinics were no longer classified as safety-net providers, which means that they were no longer exempted from the “best price” calculations used to determine how much the pharmaceutical companies should charge Medicaid for their drugs. In other words, the DRA gave pharmaceutical companies a clear disincentive to continue offering the products at reduced prices to select clinics. The end result: pharmaceutical companies started charging college and university clinics higher prices for birth control.
And so, Megan Danna’s pills leaped to over 50 dollars per month.
Many students at Yale aren’t clear on what happened. Even student activists who have protested the legislation — or defended it — are willing to admit that their understanding may be vague.
AJ Espinosa ’10, a member of the Party of the Right, wrote a letter to the Yale Daily News on October 29 arguing against suggestions that Yale should step in where the government stepped out and start subsidizing birth control. But he thought the DRA ended a government subsidy rather than prompting a price hike. “It’s my understanding that these companies choose not to offer [birth control] at that price, and they only have done so in the past because the government has subsidized the contraception,” he said over email.
But at Yale, students who have at least a cursory understanding of the DRA are the exception rather than the rule. In fact, it seems that most students haven’t even heard of the price increase, let alone the explanation behind it.
When RALY held their phone-a-thon, they attracted the attention of 60-70 students, Rahman estimates. Both Hunter and Rahman agree that most of these students hadn’t heard of the price increase. Only a few women said the increase had affected them, and those who had heard of it didn’t usually know why it had happened. “People were very surprised,” Rahman told me.
“I don’t think a lot of people knew about it. It was an issue that wasn’t really out there. We were able to alert a lot of people to the issue,” Hunter agreed.
Even more remarkable is that those who do know, Hunter added, aren’t pointing any fingers — but this non-combative approach may be the right idea. She, other Yale students, some politicians, and Planned Parenthood officials all agree that the excluding of college and university health clinics from among those safety-net providers eligible for the low pricing was simply an “oversight.” There exists no cry to snatch reproductive rights back from some conservative oppressor, or a rally against an active threat to women.
“The way I understand it is that [the DRA] provided a disincentive to pharmaceutical companies to offer birth control to college [clinics]. So no, it was not intentional. Birth control was not targeted,” Hunter told me.
In a response to Espinosa’s letter to the News, Leah Anthony Libresco ’11 argued in an October 30 letter to the News that the university should support reproductive rights by subsidizing birth control. “The University should continue trying to find a workaround to lower the cost of contraception, so that undergraduates can make decisions based on personal morality, not fiscal necessity,” she wrote.
Tait Sye is a spokesperson for Planned Parenthood Federation of America, which supports legislation to make college and university health clinics once again eligible for nominal pricing. He, like Hunter, referred to the price change as “an inadvertent outcome of the DRA.”
Yolen of Planned Parenthood of Connecticut agreed, telling me, “From everything I can gather, it was an unintentional [consequence].”
A press release announcing Senator Barack Obama’s (D-IL), Senator Claire McCaskill’s (D-MO), and Planned Parenthood’s support for legislation to lower prices in college clinics continued the trend, mentioning that the DRA “unintentionally” raised the costs.
And lower prices may return in the near future. The Prevention Through Affordable Access Act, with 123 co-sponsors in the House, as well as its companion legislation in the Senate (co-sponsored by Obama and McCaskill), proposes to put college and university health clinics back on the list of safety-net providers, a move that would restore the low prices Yale women had become accustomed to.
But finances aren’t the only reason to support the proposed legislation. While for Yale students the concerns are finances, health, and morality, for legislators and officials the issue is unplanned pregnancy. Congresswoman DeLauro states that the prevention of unplanned pregnancies is her reason for supporting the legislation.
The act may expect some resistance from advocates of abstinence. “They’re teaching these women that they need to have this to protect themselves,” Kimberly Martinez, executive director of National Abstinence Clearinghouse, told The Christian Post.
But by and large the legislation has seemed to garner support from nearly all corners. “Planned Parenthood thinks this legislation is win-win. It’s something Democrats and Republicans agree on,” says spokesperson Sye, who adds that it is “pro-health.”
With any luck for college students, by the end of the year the act will pass and contraception will once again be cheap. Though it now seems the problem is temporary, what have these monetary concerns shown about the women who are taking oral contraceptives at Yale today?
Elizabeth Gonzalez ’10 has been taking Ortho Tri-Cyclen Lo for over a year now and paying for it out-of-pocket with the help of the YUHS Prescription Plus plan. When she went to pick up her pills last semester, she found that instead of about 15 dollars, she’d be paying over 80 dollars to stay on her preferred pill. Although Peter Steere, the assistant director of pharmacy and medication management at YUHS, told me that the pharmacy tried to give students and employees plenty of notice for the price increase through bag stuffers and notifications on their website, Gonzalez was taken completely by surprise.
“I was really annoyed,” she told me, adding that she was strapped for cash until her next paycheck came in.
But she said that she needed to stay on the pill for its contraceptive effects. “I didn’t have any other choice,” she said, especially because she didn’t think that YUHS stocked any other brands.
Actually, YUHS offers many brands of the pill, but even switching might not bring students lower prices. Steere said that if patients take advantage of the Prescription Plus plan and switch from Ortho Tri-Cyclen Lo to Lessina, a generic and less expensive brand of pill, the prescription still costs 22 cents more per day than Ortho Tri-Cyclen Lo did before the price increase. Besides, this solution is feasible only for women willing and medically able to switch. As not all birth control pills are made alike, women who opt to change their prescriptions could deal with adverse health consequences, like break-through bleeding, nausea, or depression.
So Gonzalez paid her bill, knowing that after she paid the 100-dollar deductible, the Prescription Plus plan would kick in and take care of 80% of the cost. She will still have to budget at least twice as much money per year for her birth control pill, but she has a job. The Prescription Plus plan, then, is one solution for women faced with otherwise unmanageable prices. As a result, Gonzalez mentioned no significant threat to her reproductive rights or her pocketbook; she told me that she would support the legislation that would lower the price, but she has not joined any activist protests of the price change.
In fact, Steere, who has kept track of prescriptions at the YUHS pharmacy, says that he has been surprised by how few people have switched their prescriptions from Ortho Tri-Cyclen Lo to a cheaper generic band, although he adds that the price increase at Yale may still be too recent to draw any conclusions about student behavior after it. “We have seen some. I haven’t seen as many as I might have expected,” he says. He adds that there were also rumors that clinicians were recommending that patients go to other pharmacies, although birth control pills are fairly consistently less expensive at the YUHS pharmacy than they are at Walgreens or CVS.
For some women, health complications make certain brands of pills a godsend, regardless of price. One Yale senior told me, “Let’s face it, [the pill] makes your life a little bit easier.” But she couldn’t take the low-priced Ortho Tri-Cyclen Lo because that medicine would exacerbate her migraines, which can be so severe as to paralyze her right side — even during her normal migraines, her motor functions decrease, her arms and legs tingle, and she can’t swallow. Her parents’ health insurance thus mitigated the cost of a different, more expensive pill that allowed her fewer migraines. In the face of a potentially crippling health problem, money was a relative non-issue. “Managing my health is key to me… so if something makes that easier for me, I’m going to do it,” she said. The senior admitted that even 30 dollars per month would be “a lot” to pay for the pill, but she added, “It would be something I would pay 30 dollars for because I wouldn’t be in excruciating pain.”
A freshman taking Loestrin 24 to regulate her periods explained that the low level of estrogen in her more expensive pill was necessary to avoid her own migraines. Her parents pay for her pill, and she added that the price “makes no difference” in her decision.
Another common health complaint among women is severe cramps, which the pill can help relieve. A sophomore who complained of cramps so painful that they sometimes forced her to miss class was so dependent on the pill for health reasons that she no longer noticed the price. “I just bursar it,” she told me. When I asked how much the price mattered to her, she replied, “Well for me personally it doesn’t,” although she conceded that “sixty dollars per month per person could be a lot.”
Some students differentiate between medical reasons for being on the pill and reasons of convenience. A freshman who takes the pill for medical reasons revealed that she had been taking Ortho Tri-Cyclen Lo since last summer but had never known about the low prices at Yale University Health Services because her parents paid for the pill at home. Price, she insisted, would probably not be an object for anyone taking the pill for “an actual reason,” meaning to alleviate pain, rather than simply as a contraceptive.
But other students disagree; not all needs are purely medical, it seems. A freshman who had been taking Yasmin, a popular pill among Yale women, for six months explained to me, “If you need it, you need it.” Her parents supplied both the insurance and the co-payment for her pill. She and another freshman I interviewed — whose parents also paid for her pill — described their need for the pill as “convenience.” Neither believed that women were targeted for high prices; a necessity was a necessity.
Other women I interviewed didn’t even know how their pills were paid for. Another freshman, who was on the pill for medical reasons, told me, “I think it’s through my parents’ insurance.” She had been on the pill since she was 13 in order to regulate a period that came as often as 3 times a month, and her parents had always covered the costs.
Even some women who weren’t on the pill seemed to think that price would not be a problem for even less affluent Yale women, because reproductive health and safety is an important cost to bear. A freshman who is not on the pill told me that she is on financial aid, and that her parents would never help her pay for a contraceptive. But she added, “If I still needed to be on the pill, I would be on it,” even for only contraceptive motivations. Another freshman held a similar opinion, saying, “You can’t do much [else] if you want to be on it.” She distinguished between necessity and want, but added that her parents would help her pay if she needed the pill. Like many of her fellow students, her needs transcend dollar signs.
Although the proposed Prevention Through Affordable Access Act would lower prices and alleviate the concerns of all women worried about the price change, it seems likely that, just as the increase went mainly unnoticed, so will the return to the original prices. In the meantime, it seems that women at Yale will continue to pay for their health — or, more likely, allow their parents to pay. The fight for reproductive rights will have to wait for another day.