Planned Parenthood's Pricey Pills

By Kara Jesella, Nerve.com. Posted February 27, 2006.

Conservatives paint Planned Parenthood as an abortion mill and birth-control factory, an institution that doles out emergency contraception to teenage girls like Halloween candy.

But a few years ago, I realized birth control wasn't quite as easy to get as I (or the religious right) thought. The first clue: a few teenagers I regularly interviewed for stories told me that they had stopped taking the Pill. Even if they had a doctor they trusted, they didn't want to use their parents' insurance -- too easy for mom and dad to find out -- and they didn't have the cash to pay out-of-pocket.

What about Planned Parenthood, I asked? "It's not an option," one of them -- we'll call her Hannah -- told me last year, when she was 17 and a senior in high school. "They charge $100 a session and $40 per pack of birth control. Teenagers can't afford it unless they're under 15."

Hannah tried to find less expensive services elsewhere, but without much luck. She's resorted to using condoms, less effective than the gynecologist-recommended two forms of birth control (particularly important for those abstinence-only students who aren't allowed to get the roll-a-rubber-on-a-banana demo in school) and, of course, requiring the cooperation of not-always-willing teenage boys.

Planned Parenthood Federation of America serves one in four American women during their lifetime. It's widely considered the most convenient and reliable provider of low-cost birth control. It's been that way since 1970, when Title X, the family-planning program of the Public Service Health Act, was passed. (George Bush Sr. was one of its primary sponsors.)

Whereas PPFA had once been small and funded entirely through private donations, Title X "was seed money to start family planning services all over the country," says Gloria Feldt, who stepped down as the organization's president last year. The result, she adds, "cannot be underestimated."

For the first time, women could decide when they wanted to have children and orchestrate the rest of their lives accordingly. So when did it become "not an option" for vulnerable young women?

According to Planned Parenthood representatives, Hannah should have gotten her pills for free. But that's something she didn't understand (and I can vouch that she's pretty sophisticated). It's unlikely the clinic meant to refuse her services because she couldn't afford them: Title X requires that a health center not turn away anyone under the federal poverty line. And it's Planned Parenthood's mission, according to Jodie Curtis, assistant director for government relations for PPFA, not to turn away anyone at all. When it comes to those not covered by Title X, she says, "it is up to Planned Parenthood to figure out how to help those people subsidize the cost if they can't pay. Some states have programs to help with this, and many Planned Parenthoods fundraise to help patients cover the cost of services." Plus, PPFA is allowed to assess teens on their own income level, not their parents'.

Yet Hannah's story is symptomatic of a growing trend. Jennifer, 24, also tried to get the Pill through PPFA in New York. "They were very unhelpful," she recalls. "I didn't have insurance, and they just couldn't comprehend why I didn't. They kept making hints about how they assumed I could afford it and thus it was my negligence. But I really couldn't afford it."

For some girls, the cost of the Pill has become so prohibitive that they're tempted to switch to more affordable methods. At PPNYC, a pill pack is free for insured patients; for those without insurance, it can cost up to $20 on a sliding scale. On the other hand, Depo-Provera is included in Planned Parenthood's visit fee; there's no additional cost. "That's alarming to me, as I think it offers an inappropriate incentive," says Judy Norsigian, the executive director of Our Bodies Ourselves, the women's-health advocacy organization. "Just because a method is free doesn't mean it's necessarily the right one."

In fact, she says, because Depo-Provera is associated with a loss of bone density in young women, it's important to consider alternative methods first.

There are other reasons the organization's reputation isn't as pristine as it once was. Women I spoke with reported clueless receptionists and lines worthy of the DMV. (One woman says she waited three hours to see a doctor for the morning-after pill; eventually, she got the prescription but never did get to see a doctor.) Voicemail systems are hard to navigate; many have actual people answering the phone only during business hours, when most women aren't able to deal with their reproductive-health issues.

Twenty-five-year-old Erin left her local clinic without the morning-after pill when told it would cost $50. When she said she'd try to get it cheaper somewhere else, the receptionist made her feel guilty for taking the last appointment of the day, causing another girl to be turned away. "They were honestly a bit curt, and there was a sense that it was a service for low-income people and therefore a bit of a cattle call," adds Erin. "I say this with great hesitation, because I really believe in Planned Parenthood, and I'm deeply grateful that it exists. It's one of very, very few options for women without health insurance to get their ob-gyn options taken care of."

No one -- including me -- wants to take potshots at an organization that strives to do important work. And I'm not suggesting that PPFA has a lock on miscommunication or poor bedside manner. (A gynecologist who regularly appears in glossy magazines recently misdiagnosed my friend with herpes; she actually had an ingrown hair.)

But there are already so many barriers for women trying to get contraceptives: Some states are trying to pass laws requiring clinics to notify the parents of teens who request birth control; there is a proposal in South Dakota to fine public school teachers $200 and impose jail time if they refer students to family-planning services; and young adults ages 19 to 29 are one of the largest and fastest-growing segments of the U.S. population without health insurance. This makes high-quality, low-cost reproductive health care at PPFA all the more necessary. And it makes what one woman calls the "aggressively unhelpful" staff at an Austin clinic and a sign that read "A lack of planning on your part does not constitute an emergency on mine" all the more alarming.

So what's going on? When Hannah was quoted a high price for birth control pills, "maybe she got someone new," suggests Dr. Vanessa Cullins, PPFA's vice president for medical affairs. Feldt agrees: "Entry-level jobs are hard. They're often held by young people just starting out. That doesn't mean they're not smart, but they may not have as much experience in delivering complex messages about sliding scales and government-funding restrictions."

In fact, according to a 2003 report by the Alan Guttmacher Institute, many Title X clinics spend significant amounts of money training rookie staffers to perform critical functions, from scheduling to client intake, only to see them lured away by private physicians with the promise of larger salaries. Then the money-losing cycle begins again, and women end up dealing with new people at every visit. (Clinics are having trouble hanging on to other medical providers for the same reason.)

Hannah did have recourse, says Cullins: "Every affiliate has a vice president of patient services, director of patient services, or clinic manager, and they need to be aware of that," she says. Of course, most people aren't. "Most agencies that provide free or low-cost services don't have tremendous resources," Cullins adds. "They may have an inadequate phone-response system. You need to be patient. If you're trying to get through to a health department, you may get transferred a couple of places."

The problem, she says, is lack of funding. Health-care costs -- from Pap smears to pathology labs -- are skyrocketing. The cost of contraceptive supplies has risen sharply as well, particularly for newer, longer-lasting methods with lower failure rates. More money is being spent hiring staffers who speak multiple languages. Plus, Title X money is now being spent on a broader range of services, like STD testing. And the president's appropriations for the program have stagnated. Right now, Title X's annual allotment is $283 million a year; if it kept pace with inflation, that number would be $693 million. But instead of increasing funding, the Bush administration is funneling money to abstinence-only education, which doesn't provide information on contraception -- or health care.

In addition to the low-income and the regionally isolated, it's teenagers and young women who are affected -- it's estimated that 30 percent of federally funded family-planning recipients are under the age of 20, and 50 percent are 20 to 29. As more people lose their insurance, they turn to clinics. Yet funding doesn't keep pace. "It doesn't matter if you serve one or 1,000 patients, you get the same amount of money from Title X," says Jodie Curtis, assistant director for government relations for PPFA. "It's not like Medicaid, where you get reimbursed per patient." Many PPFA health centers even provide primary care services, like diabetes testing, and provide referrals to specialized health care."We really are the entry point for broader health care," adds Curtis. "If people aren't coming in to see us, chances are they aren't coming in for health care at all," she adds.

Ultimately, less money means more miscommunication. "When I started out 30 years ago, there was plenty of money for counselors as well as medical care providers," says Feldt. "Counselors are very experienced and expensive. My observation is that that's where a lot of the cuts have been made. For patients who have other kinds of emotional problems, there's less counseling staff to spend extensive time."

And though, in the words of Danielle Tierney, a spokesperson for PPFA's Austin affiliate, "Planned Parenthood is a health care provider, first and foremost," the organization has also been on the front lines of important reproductive health care battles, fighting for a woman's right to an abortion, for over-the-counter availability of Plan B and for teenagers to have access to birth control. "The wonderful day should come at some point when all of our concerns would be about providing the best quality of care, not fighting people who want to eliminate family-planning programs," says Feldt.

That day seems far in the future. The Senate just passed a $38 billion deficit reduction that dramatically cuts Medicaid and Medicare services. According to the New York Times, 13 million low-income people face new or higher copayments for medical services. More than 100,000 will lose health-care coverage altogether. And federally funded health clinics will have to pick up the slack. ("We now know who is sacrificing in order to help pay for the war in Iraq: the poor and their children," read a San Jose Mercury News editorial on February 1.)

So clinics face difficult choices. PPFA's Austin affiliate recently found out they would have to sustain a 45 percent cut in federal funding. PPFA officials decided to tell 6,000 clients they were no longer eligible for services at the downtown location. Hours were cut from 55 a week to 24. The clinic is now dedicated entirely to women 24 and younger. "We hope women 25 and over will be able to use one of our for-fee clinics," says Tierney, with a sigh.

Of course, many of those women can't afford to. Last year, a government study found that adult women were opting out of birth control in surprising numbers. "It seems to represent access problems and affordability," says Jeffrey Jensen, director of the Women's Health Research Unit at Oregon Health and Science University. Even patients with private insurance often can't afford the copayments. Plus, he adds, drug companies have cut back on free samples. As a result, women turn to less-effective types of birth control and run a greater risk of unwanted pregnancy.

Though other federally funded clinics are facing the same constraints as PPFA, there are a few options for women looking for low-cost birth control, such as college health centers. (One woman was given a year's supply of the Pill when she graduated.) The online pharmacy SmartWomanRX offers inexpensive pills, though it only carries a few brand names. It can be cheaper to buy emergency contraception in advance and keep it on hand, just in case: Not 2 Late has a list of providers around the country (though not how much they charge). Go to the PPFA website to find out how to use regular birth-control pills as emergency contraception if you need to.

Beyond voting for candidates that support family planning, women who get health care at PPFA and can afford to pay the higher price on the sliding scale should do so (as one woman pointed out, if you have enough money to buy the Diet Coke to drink on the way there, you should be prepared to pay something). If you're in a financial bind, you can tell the nurse or doctor that you want to go on birth control and tell them how much you think you can afford to pay.

In her book "The War on Choice: The Right-Wing Attack on Women's Rights and How to Fight Back" (Bantam), Feldt cites the successful campaigns to get insurance plans to cover contraception; she suggests going to Cover My Pills for information on how to take action. She also notes that the Prevention First Act -- which would dramatically increase Title X funding, increase access to emergency contraception, and require sex education to be medically accurate, among other provisions that would expand access to reproductive health care -- is languishing in Congress because the anti-choice leadership won't let it come up for a vote.

"The votes are there for passage were it to come to the floor of Congress," she says. "Grassroots pressure could make that happen. That's where joining organizations with alert networks, writing letters to the editor, raising the issue at your members of Congress' town halls, and stirring up your friends can make a big difference."

Certainly, PPFA can't find these battles alone.

Kara Jesella is a freelance writer in New York City. She is currently co-writing a book on Sassy magazine for Farrar, Straus & Giroux.

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