What’s at stake in the IOM Report?

Screenshot of Institute of Medicine recommendations on coverage of birth controlThe Institute of Medicine (IOM) recently announced recommendations regarding mandatory insurance coverage with no co-pays for women’s preventative health care services under the new health care law. Predictably, a firestorm has ensued.

This is because one of the eight services recommended is coverage of all FDA-approved contraceptive methods. Professional medical organizations and health advocacy group have vigorously applauded this move, while the longtime opponents of contraception—the Catholic Church hierarchy, conservative groups such as the Family Research Council, right-wing media personalities—have just as vigorously denounced it. As of this writing, it is not clear how the Obama administration—and in particular, Kathleen Sebelius, head of the Department of Health and Human Services—will respond to this recommendation.

What’s at stake in this conflict? Most immediately, of course, those women who have difficulty coming up with the co-pays for the more expensive (and more effective) forms of contraception, particularly the pill, the IUD, and injectables, will benefit greatly.

But the stakes go beyond the immediate beneficiaries. The IOM’s action draws attention to some of the contradictory facts about contraception—both its usage patterns and its shifting political meaning—in the United States, and the extent to which contraception has become yet another front in the nation’s unending culture war. On the one hand, use of contraception is virtually universal among heterosexually active American women. But nearly half of all pregnancies in the United States are unintended, illustrating that such use is episodic.

Moreover, contraception has become inextricably bound up with the even more divisive struggle over abortion. Defenders of contraception have long portrayed it as “common ground” in the abortion debate, arguing that the former prevents unintended pregnancies, thus reducing the need for the latter. In contrast, opponents of contraception claim that it “is supportive of the abortion mentality”—that is, those who use contraception are more likely to seek abortion in the event of a contraceptive failure.

In a more recent twist, opponents have claimed that many forms of contraception are themselves “abortifacients.” The recent high-profile campaigns by social conservatives to defund Planned Parenthood illustrate how tightly joined the battle against both phenomena has become. In this light, the acknowledgment by the U.S. government that contraception is an essential part of preventive health care would represent a huge step in the legitimization of contraception.

Similarly, if this recommendation is implemented, it will represent a significant turning point in the longstanding war against science that has been waged by the Right. This campaign ramped up dramatically during the presidency of George W. Bush; as one of his senior advisers famously said, in regard to the Bush administration’s strained relationship to the scientific community: “We’re an empire now, and when we act, we create our own reality.” Along with environmental issues, reproductive health has been a central background in this war: remember the governmental websites, during the Bush years, that proclaimed the false link between abortion and breast cancer, and that posted gross misinformation about condom effectiveness? Or the federally funded “abstinence only, until marriage” curricula that were rife with blatant untruths, such as the claim that HIV can be transmitted through sweat and tears?

In his inaugural address in January 2009, Barack Obama directly rebuked the Bush record on science by forcefully proclaiming, “Science will have a rightful place in my administration.” The IOM report represents science at its best: an exhaustive review, by an expert panel, of the best available evidence to guide policy in the field of public health. The fate of the IOM report will offer a telling guide to the place of science at the current moment.

Update

On August 1, the Department of Health and Human Services announced it has accepted the IOM recommendations, with an exemption for “religious employers.”

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