On the evening of November 8, Megan Squires gathered at the Isaac Hunter's Oak City Tavern in downtown Raleigh with about one hundred supporters of the Wake County transit referendum to watch the election results roll in. The mood was festive and restless at first. But as state after state went for Donald Trump, Squires felt an increasing sense of dread.
Aside from the transit referendum's victory, things were looking bleak for North Carolina and the country. Upon leaving the bar, Squires began crying. She even let out a scream of rage, uncharacteristic of the normally subdued twenty-nine-year-old. The possible repercussions of a Trump victory raced through her mind, and one of her first concerns was what the new administration could mean for reproductive rights.
"I have a friend who I was watching the election results with, and, unrelated, she had an appointment to have a Skyla inserted the next day, so we were all just kind of sadly joking, 'At least you're getting that,'" Squires says.
She wasn't alone. With a Trump presidency—and the threat of a reproductive-rights rollback—looming, women across the country felt the urge to set up appointments for long-acting reversible contraceptive devices, like Skyla, that would outlast a Trump administration. In fact, the day after the election, Google Trends showed a huge spike in searches for "IUD" (an acronym for "intrauterine device"), "Planned Parenthood," and "birth control," as NPR reported last month.
"Since the election, we have seen an uptick in questions about access to health care, birth control, and the Affordable Care Act," says Dr. Raegan McDonald-Mosley, chief medical officer at Planned Parenthood, in a statement. "While we truly hope that birth control methods will be available, accessible, and affordable to all women under the Trump administration, we understand people's real concerns about losing access to birth control, which is basic health care for women."
Squires, who has interned for Planned Parenthood, had considered getting an IUD before, but she'd put off setting up an appointment, in part because of how painful she'd heard the insertion can be. After the election, Squires stopped procrastinating. (She also decided to live-tweet her November 30 insertion from her newly created Twitter handle, @sexlifepositive.)
Squires recently moved back to Carrboro from Chicago and is insured through the Affordable Care Act's health care exchange while in between jobs. Thanks to the ACA's contraceptive mandate, Squires can get an IUD inserted without a copay. Without insurance, the combined cost of the medical exam, the IUD, and insertion can range from $500–$900, according to Planned Parenthood.
Squires opted for the ParaGard, a nonhormonal copper IUD that lasts up to ten years. Other options for long-acting reversible contraception include other IUDs, such as Mirena (which lasts five years) and Skyla (three years), and the contraceptive implant, a tiny rod inserted under the skin of the upper arm that is good for three years.
"I'm fine with the birth control I have now, but the election has made me scared for women's rights," says Laura Paskoff, a Raleigh twenty-four-year-old who plans to utilize Mirena. "I don't want my rights taken away from me, so I felt like I should do this while it's covered through my insurance."
Squiers and Paskoff aren't the only local women with these anxieties.
"We have had a few patients specifically state that that's the reason they wanted to either come in for a new visit or have their IUD replaced a little bit earlier than is necessary, just so it wouldn't be an issue," says Dr. Beverly Gray, an ob-gyn at Duke Medicine and director of the Ryan Family Planning Clinic. "As far as the ACA mandate that insurance cover birth control, I think it's definitely possible that that mandate could be taken away. Whether or not insurance companies decide that it's cost-effective—which it is cost-effective to provide effective contraception to patients—that has yet to be seen."
According to Gray, studies show that when women have no cost barriers, about 75 percent will choose either an IUD or a contraceptive implant, which in turn reduces the rates of unplanned pregnancy and abortion.
Adam Sonfield, senior policy manager and executive editor for Guttmacher Policy Review, says that even before the contraceptive mandate went into effect, most insurance plans were already covering a full range of contraceptive methods. The biggest change is that the ACA requires plans to cover every single method with no out-of-pocket costs.
"Plans weren't necessarily doing all of that beforehand," he says. "They were covering a wide array of methods, but not necessarily all of them, and they were trying to encourage women to use cheaper methods rather than ones that were more expensive up front for the insurance company. They were penny pinching in various ways, even though those methods that are more expensive up front may be cost saving for the insurance plan in the long run because they can be more effective. If this requirement were eliminated, it's possible that we could see some insurance companies reverting back to what they did before."
Even if contraception remains available, higher prices for birth control will effectively limit some lower-income women's options. A survey commissioned by the Planned Parenthood Action Fund in 2010 found that a third of women surveyed struggled to pay for prescription birth control, which at the time cost $15–$50 each month.
Despite the evidence, some politicians—namely, Trump's pick for health and human services secretary, U.S. Representative Tom Price, R-Georgia—have denied that any woman has trouble paying for birth control. At the 2012 Conservative Political Action Conference, Price said, "Bring me one woman who has been left behind. Being me one. There's not one."
Price has consistently voted in opposition to the ACA's federal contraceptive mandate, which he and other conservatives view as antithetical to religious liberty. (In the 2014 case Burwell v. Hobby Lobby, the U.S. Supreme Court ruled that "closely held" for-profit corporations could claim an exemption to the mandate.) There are several ways in which the new administration could attack it.
The administration could decide to no longer endorse the recommendation made by the Department of Health and Human Services in 2011, which included contraception in the list of preventative services for women that should be covered under Obamacare. Trump could also expand the current exemption for employers who invoke a religious objection to birth control. Or, with the help of Congress, the administration could repeal or modify the Affordable Care Act, and with it the birth control provision.
"The birth control provision has helped tens of millions of women in the country," Sonfield says. "It has reduced a cost barrier to women choosing the contraceptive method that works best for them at a given point in their lives, and to plan whether and when to have children, with all the benefits that means for them in terms of helping them stay in school and get a good job and care for their family. Undermining or eliminating this provision would do a lot of harm to a lot of people."
The uncertainty has made some women who are satisfied with oral contraceptives look into longer-term options.
"I've considered getting an IUD a couple of times, but birth control in the pill form has always worked for me," says Sarah Nolan, a Duke graduate student. "It's weird to have this very personal decision made for me due to circumstances very outside of my control."
Nolan will turn twenty-six one month after Trump takes office. She'll be forced off her parents' health insurance and on that of her employer.
"Right now I'm on the birth control pill, which is great, and it's free to me through my parents' health insurance every month," she says. "I don't have to do an economic calculation every time I go to pick up my prescription; it's just there as part of my health care system. In a few months, I might have to put a monetary value on it—how much is that convenience of a birth control method that works for me worth in terms of dollars? Do I have those funds in my monthly budget? It might not end up being all that much, but if you add up a twenty- or thirty-dollar copay each month over a year, it starts to seem more significant."
This article appeared in print with the headline "Grab Them by the Uterus."