The Surprisingly Fraught Question of Who Pays for Birth Control
The burden of many of the most common contraceptive methods falls on women. Some heterosexual couples try to fix that imbalance by splitting the cost.
In 2017, Taylor Kay Phillips was debating two things: whether she wanted to switch from the pill to an IUD, and, if she did, whether she should ask her boyfriend, Felipe Torres, to help pay for it. At the time, Phillips—now a comedy writer in New York City—was unemployed, and her insurance plan wouldn’t cover the $1,100 bill. But she was hesitant to ask Torres to pitch in. Phillips didn’t know anyone else who had split the cost of birth control with a partner, and she had questions. If her boyfriend paid for part of her IUD, would that mean she had less autonomy over her own body? They had been dating for only a few months, and copper IUDs, the type that Phillips wanted, typically last for up to 12 years; if she and Torres broke up, would she need to reimburse him? But when they sat down to talk about the IUD, he offered to pay for half before she could ask. “It just seemed like the fair, right thing to do, since I was also reaping the benefits,” Torres told me.
During their conversation, they acknowledged that while both of them would be responsible for an unwanted pregnancy, much of the burden—physical, but also emotional—would fall on Phillips. They wanted to balance out that burden, financially. Although I wasn’t able to find any statistics on the exact number of couples who share the cost of contraception, many of the researchers and individuals I spoke with said that, in their experience, cost-sharing is not the norm among heterosexual couples.
Under the Affordable Care Act, many women in the United States have gained access to free birth control, but some still have to pay in certain circumstances. Insurance companies don’t need to cover brand-name contraceptives, just generic versions. Short-term, often low-cost insurance plans aren’t required to cover contraception at all. Religious employers can apply for an exemption that allows them to drop contraceptive coverage from their plan. And women without insurance have no choice but to pay for birth control out-of-pocket, or go without.
Nearly 65 percent of women ages 15 to 49 currently use some form of contraception, according to the most recent available data from the Centers for Disease Control and Prevention. The cost of birth control can vary dramatically depending on the type. According to Planned Parenthood, IUDs can cost up to $1,300, and hormonal pills can cost up to $50 a month, or $600 a year. When factoring in the cost of an annual visit to a gynecologist or other doctor, the bill can be even higher.
Many common forms of birth control can be obtained only through a doctor, and as a result, many women bear the brunt of the costs, in terms of both time and money, including setting up appointments, getting refills, and paying for contraception. These burdens are even heavier for poor women, especially those living in “contraceptive deserts,” areas with limited access to birth-control clinics. Sharing the cost of contraception with a partner can help alleviate some of that financial strain and symbolically demonstrate that a couple views preventing pregnancy as a joint responsibility. When Torres and Phillips decided that they were going to split the cost of Phillips’s IUD, they devised a payment plan in which Torres would Venmo Phillips $200 each month, for three months. Phillips told me that while she views sex as a “shared endeavor,” the duty to prevent pregnancy is “fundamentally unequal,” in that she “can get pregnant and he cannot.” She added: “I had to go in and have a legitimate medical procedure, cramp up, and bleed extra for a year. And he got to have condomless sex with, basically, abandon.”
Katrina Kimport, a medical sociologist at the University of California at San Francisco, told me it’s not surprising that few heterosexual couples share the cost of birth control. She studies women’s experiences with abortion and contraception, and pointed out that the most highly effective, long-acting, and commonly used forms of birth control—for example, IUDs and oral contraceptives—physically operate in women’s bodies. In her research, Kimport has found that even when women visit family-planning clinics, medical professionals frame preventing pregnancy as a female responsibility. As a result, both partners in a relationship may assume by default that women should be in charge of maintaining, and paying for, contraception.
Financial costs are just one of the burdens of preventing pregnancy. There are also mental, physical, and emotional tolls to consider. “It takes time to go to the doctor, go through the physicals, and go to the pharmacy,” Julie Fennell, a sociologist at Gallaudet University in Washington, D.C., told me. “It’s not a huge deal, but it is something that adds up, especially if you’re poor and you have limited access to these things.” Even after acquiring a prescription or getting an IUD insertion, the work isn’t done—a person may have to remember to take a pill at the same time every day or go to the pharmacy once a month. There are common side effects such as depression, weight gain, and irregular bleeding, and rare, debilitating ones such as pelvic inflammatory disease, blood clots, and ovarian cysts. “I don’t think there’s any broad social discourse that encourages empathy for the difficulty that some women face in successfully contracepting,” Kimport said. In fact, she has observed “an overall downplaying of the effects of side effects and how disruptive they can be.”
For couples whose contraception is covered by insurance, the issue of cost-sharing may still come up when discussing another common type of birth control: condoms. In a 2016 survey by Trojan and the Center for Sexual Health Promotion at Indiana University, 65 percent of women said they had never bought condoms, although 68 percent of women didn’t think that providing them should be solely a man’s job.
However, some men, such as William, a 23-year-old researcher living in Bethesda, Maryland, view buying and supplying condoms as a male obligation. William says he has never been with a female partner who bought or offered to buy condoms. (William asked to be identified by his first name only so that he could discuss his sex life openly.) He told me that when he and his current partner started having sex, they had a formal discussion about how they would pay for birth control. William’s partner pays for the pill since she takes it for noncontraceptive reasons, while he buys the condoms. He has also offered to pay for Plan B, should they ever need it, because if the condom were to break, “it’d probably be my fault,” he said. If he and his partner shared other costs such as rent or food, William said that dividing their expenses by total cost, and not by item, would make more sense. But William stressed that he wasn’t opposed to doing so in the future. “As a concept, I would be open to helping pay for it if asked. I don’t really have any strong reservations against that,” he said.
Samantha McDonough, a 51-year-old living in Virginia, approaches cost-sharing differently. She is polyamorous but currently in a long-term relationship with one partner. Though she has had her tubes tied, she still uses condoms, and typically takes turns buying them with her partner. When she was seeing multiple partners, condom use was even more nonnegotiable, and she made sure that both she and her partners had them.
McDonough has two daughters, and she has tried to encourage them to be proactive about using protection. Yet she told me that she “didn’t want to give them the impression that they should carry the cost on their own. I just wanted to let them know that they had to make sure that they thought about protecting themselves first and didn’t rely on someone else to do that.” She believes that while everyone, especially women, should do their part to have safe sex, looking at contraception as a shared expense has many benefits.
Cost-sharing isn’t the only way that couples reallocate responsibilities surrounding pregnancy prevention. In 2007, before the ACA passed, Fennell interviewed several heterosexual couples for a paper she titled,“Men Bring Condoms, Women Take Pills: Men’s and Women’s Roles in Contraceptive Decision Making.” While some men gave their female partners money to help pay for contraception, others set alarms to remind them to take the pill at a specific time, or went with their partners to doctor appointments. Still, Fennell said that although many women wanted their male partners to take a greater interest in contraception, most still “wanted to be the [one] making the final decisions,” because they felt uncomfortable with the idea that their partners had sway over what they did with their body.
Even couples who do share the cost of birth control, such as Phillips and Torres, are hesitant to prescribe it as something that every couple should do. For Phillips, splitting the cost for contraception felt natural, as they were already thinking about their finances jointly—she helped Torres, an immigrant from Colombia, pay for his visa and lawyer fees. In late 2019, they got engaged—both the IUD and the relationship have lasted. Kimport noted that cost-sharing “may not work for everyone,” and may not resolve feelings of inequality within a relationship. But, she said, “it is still a creative way of disrupting this idea that because most popular contraceptive methods operate in female bodies, they should be exclusively women’s responsibility.”