Democrats urge Biden to ensure broader access to free birth control

• Persisting coverage hurdles are also making it more difficult for patients to access newer forms of birth control that are more effective and have fewer side effects, advocates say.

Driving the news: Sen. Bernie Sanders (I-Vt.) and other Democratic members of Vermont's congressional delegation, Sen. Peter Welch and Rep. Becca Balint, last month called on the administration to bolster enforcement of mandated birth control coverage.

• They pointed to Vermont regulators' recent order for three insurers to repay more than $1.5 million after an investigation found more than 9,000 patients were inappropriately charged for contraceptive costs between 2017 and 2021.
• Medical claims for services related to contraception — including office visits, pregnancy tests, sexually transmitted infection testing and sterilization — were being incorrectly processed because of coding problems and differing interpretations of the ACA mandate, the investigation found.
• The scope of Vermont's investigation was limited to state-regulated health plans and specific contraceptive services, so it didn't include most employer-sponsored coverage — a big chunk of the insurance market.
• The Vermont investigation "really is the tip of the iceberg," Mara Gandal-Powers, director of birth control access at the National Women's Law Center, told Axios. "It points to the need for a federal fix that covers everything."

The Vermont report was hardly the first to flag gaps in mandated birth control coverage. Democratic lawmakers over the years have called attention to reports of insurance denials.

• The Biden administration last year also reminded insurers of their coverage obligations after receiving increasing complaints, and it's also looking at new ways of expanding access to birth control.

Between the lines: Under the ACA, most insurers are required to cover at least one form of each FDA-approved contraception method at no cost. That leaves a range of products that insurers don't have to cover.

• Patients can appeal to their health plan through an exception process if their prescribed birth control isn't on the list of covered drugs, known as a formulary.
• However, patients report difficulty obtaining coverage for excluded products, particularly the newer forms.

Zoom in: For instance, a low-dose estrogen patch from Agile Therapeutics is often not covered because a generic patch with a higher dose of estrogen is on the formulary, Gandal-Powers said.

• "They're just being left out of the market," she said. "And this has happened with several other of these pharmacy products like [contraceptive gel maker] Phexxi."

• Her organization is calling for the federal government to require that insurers automatically cover contraceptives without out-of-pocket costs if there's no therapeutic equivalent on the market.
• Something like the low-dose patches, which are best suited for certain patients, should be considered "therapeutically distinct" from other patches, and guidance should require automatic coverage, said Dana Singiser, a health care policy expert at Keefe Singiser Partners.

The other side: The big insurers' lobby AHIP has said its members comply with requirements to provide birth control coverage without cost-sharing.

• "Our commitment is the same as it's been for many years, and we continue to work hard every day to ensure that people have access to the preventive services they need and deserve," a spokesperson wrote to Axios.

What we're watching: The Biden administration could soon make key decisions about birth control access.

• In June, the White House issued an executive order calling on the Health and Human Services, Treasury and Labor departments to consider issuing guidance expanding access to all FDA-approved contraception without cost-sharing.
• And in September, the administration called for input on whether to mandate that insurers cover over-the-counter products, ahead of the expected arrival of the first birth control pill to be sold without a prescription. The ACA coverage requirement doesn't include over-the-counter methods.
• AHIP told the administration it supports expanding coverage of over-the-counter birth control with some guardrails, like requiring patients to obtain the medication at in-network or preferred providers and pharmacies.
• HHS declined to comment on the timing of new guidance for insurers on contraception.