As we wait for the Supreme Court to render a decision on the Hobby Lobby contraception coverage case, I have been pondering the historical relationship between contraception and health care. Is it obvious that contraception should be considered part of “health care”? And would it be possible to decide that it isn’t, but still make it affordable and available?
This case seems, to me, to rest largely on whether we think contraception counts as health care. The justices are wary of an outcome that would allow employers to decline to pay for blood transfusions or routine vaccinations, even if an employer might genuinely have religious reservations about those procedures. Those are clearly health care. Contraception, though, seems different. It is prescribed for healthy people, and it does not cure or prevent disease (at least not directly).
Before we dismiss this argument as disingenuous excuse-making on the part of Obamacare’s opponents, it’s worth remembering that 1960s feminist health activist Barbara Seaman said it first. She felt that the birth control pill was foisted on women, with inadequate testing and false reassurances, by overconfident and condescending doctors. When it became clear that in some cases, birth control pills caused deadly strokes, she successfully pressed Congress to investigate. Seaman seemed ready to see the pill pulled from the market. The compromise was to create the first patient information insert for a prescription drug. Seaman and others held the pill to a higher standard than other drugs, not only because it affected millions of women, but also because she did not think the risk of getting pregnant was the same as the risk of becoming ill.
Thinking much farther back, before the nineteenth century contraception was certainly considered part of healthcare. Only it wasn’t exactly considered “contraception.” In early modern Europe and colonial America, mothers cared for themselves and their families when they were sick. Missing a period could be understood to be a sign of pregnancy, but it could also be read as a sign of illness. Depending on the circumstances, a woman might treat a missing period with herbs to try to bring on her menses, hopefully restoring her health. She also might take herbal remedies at the time of her expected period, as a way of staying ‘regular’ and preserving her health. Contraception was part of health care because it wasn’t explicitly considered contraceptive; it was folded into menstrual cycle health. And women generally took care of their own menstrual cycle health, unless they had problems beyond what they could manage, because that’s how they handled all health care for themselves and their families.
In the nineteenth century, contraceptive efforts became much more explicit. Birth rates fell dramatically. Couples used withdrawal, douching, condoms, and sometimes pessaries to try to avoid pregnancy. They still did not typically consult doctors for assistance, though, unless a woman was seeking an abortion. And in fact, many doctors were reluctant to provide abortions and had qualms about sanctioning birth control. In the 1870s, the Comstock Laws made it difficult for doctors to legally obtain and distribute contraceptive technology even if they were willing.
Contraception started looking more like modern medical care in the 1930s, when the Supreme Court protected doctors’ right to prescribe contraception as part of their patients’ care. There had been a cultural sea change by that time; the roaring twenties had made sex, and contraception, much more acceptable, and many doctors sanctioned marital use of birth control. Physicians prescribed diaphragms to many of their middle-class patients.
But the serious medicalization of contraception came with the birth control pill, in 1960. It was developed in a medical setting and resembled previous hormonal medical treatments. It was marketed as a prescription drug, and given widespread concern about short and long-term side-effects, it was decades before there were serious proposals to make it available over the counter. Even then, public health advocates argued that since women came in for pap smears and other annual preventive care in order to get their pill prescriptions, the pill ought to be kept prescription-only. It still is.
The pill was followed most notably by the intrauterine device, which requires some medical expertise for insertion and removal, and by surgical sterilization techniques, which require a great deal of medical training. At this point, most of the popular, effective contraceptive methods require a medical prescription or procedure.
So is current-day contraception “health care”? Some contraceptive techniques clearly can’t be removed from the medical system. For a vasectomy, you need a surgeon. If you can’t take the contraceptive technique out of the medical system, I don’t think you can take the insurance away from the contraceptive technique.
Other contraceptives, though, might become much more affordable and accessible if they were given some distance from the medical health care system, but still given public support. Birth control pills could be available over the counter. Specialized nurses could insert IUDs more safely than physicians who insert them only occasionally, since safety is based mostly on practice with the procedure. Planned Parenthood has found ways to provide contraception more affordably than private physicians’ offices, and they and other women’s clinics could do even better given more appropriate legal and market supports.
I would hate to see Hobby Lobby win this case. Women and their partners need access to good contraception, and given our current medical system, Obamacare’s mandate seems like the mostly likely way to provide it. But I would be even happier to see more forms of modern contraception truly under women’s control, accessible and affordable whether or not politicians are inclined to pass health care laws, employers are willing to provide insurance, or doctors are available to write prescriptions. Traditional forms of contraception were available to women (even when they were outlawed!) because they were not blocked by medical gatekeepers or outrageously expensive. I would like to see modern contraception similarly available. We can legitimately argue about whether contraception is “health care.” But there is no question that it is central to heterosexually-active women’s self-determination and well-being.
Featured image source: http://commons.wikimedia.org/wiki/File:Hobby_Lobby,_Trexlertown,_PA.JPG
*Image of 19th century female contraceptions and abortifacients courtesy of Case Western Reserve University: http://www.case.edu/affil/skuyhistcontraception/online-2012/19thCentury.html