Written Submission for the Pre-Budget Consultations in Advance of the Upcoming Federal Budget - AccessBC
Recommendation 1: That the government provide funding to provinces to implement universal, no-cost coverage for all prescription contraception.
AccessBC is a grassroots, all-volunteer, BC-based group of young people concerned with access to prescription contraception. We are calling on you to include universal access to no-cost prescription contraception as part of the upcoming 2021 federal budget.
There is strong evidence to suggest that a program that makes all forms of prescription contraception available to all Canadians at no cost would be revenue positive, and furthermore, that such a policy would maximize a number of social and health indicators, increase equality, and promote a host of other benefits.
Limited access to prescription contraception can lead to unintended pregnancies, which can derail life plans and come with high personal costs. These pregnancies also increase the likelihood of negative health impacts to both the mother and child, and come with significant costs to our health and social services. Consistent use of reliable forms of contraception significantly reduces the chance of an unintended pregnancy.
Access to contraception is recognized as a basic human right, however, there are currently significant barriers preventing people from accessing prescription contraception across Canada. Canadian contraceptive care providers identify cost as the single most important barrier to access (and see source).
An intrauterine device (IUD) can cost between $75 and $335, oral contraceptive pills can cost $20 per month, and hormone injections can cost as much as $180 per year. Such costs represent a significant barrier, particularly to people with low incomes, youth, and people from marginalized communities.
While there are a small number of government programs in place that support access to contraception, these programs are largely income-dependent and vary significantly across provinces and territories. Cumbersome application processes and paperwork discourage the use of these programs and represent additional barriers for people who are often already vulnerable, time-poor, or unable to navigate complex bureaucracies without assistance.
Many provincial programs have variable deductibles and rates, are limited to low-income individuals or families, or are only available to particular eligible groups. These programs are frequently unclear or unpredictable for individuals dealing with circumstances like on-and-off separations, mixed families, or fluctuating income, all of which may affect their eligibility for provincial drug coverage plans. People in these situations are some of the most likely to benefit from the stability that simple access to no-cost contraception can bring, yet they face the highest levels of bureaucracy.
No one should have to pass a means test in order to freely exercise their right to make choices about their reproductive health.
Even in cases where a person qualifies for coverage in a provincial program, there are often significant restrictions to the contraception options that people can choose from. British Columbia provides a useful case study. A newer combined low dose estrogen and progesterone oral contraceptive pill (OCP), Lolo, is a popular option amongst patients wanting to minimize their estrogen exposure. However, Lolo is not available under British Columbia’s government-funded plans. For patients unable to take a daily pill, the current BC government plans do not cover either the combined estrogen and progesterone Evra Patch or the NuvaRing.
Another oversight under existing government plans is the copper IUD - the only form of long-acting reversible contraception for people who cannot tolerate hormones, and the most reliable (and only non-hormonal) form of emergency contraception. There are multiple brands of copper IUDs, but because they are classified as medical devices and not a medication, their coverage is variable under existing government plans, can require additional arduous steps to qualify for coverage, and too often are simply not covered at all. These deficiencies have been noted by physicians in practice as hindering patient care.
High costs of contraception are a significant problem for young people. While young adults may be covered through a parent’s plan, they are often forced to give up their privacy (by making claims through an insurance plan that their parents are able to review) in order to make choices about their bodies. This is extremely concerning with respect to contraception, given the various stigmas surrounding it, and the potential vulnerability of young people who may be forced to challenge their family’s beliefs to access care. Young people should not be forced to choose between their privacy and their healthcare in order to exercise their rights.
For people in relationships where their prescription coverage is dependent on a partner, accessing contraception can put their safety at risk. As many as one in four women accessing sexual and reproductive care have reported not being able to freely make reproductive choices, and reproductive coercion is now well-recognized as a form of gender-based violence that is frequently used by abusers against their intimate partners. Providing safe and free access to contraception gives people in abusive relationships one more tool they can use to keep themselves safe.
The current COVID-19 pandemic has magnified the existing barriers to accessing contraception in our healthcare system. The impact of cost, however, cannot be overstated. The pandemic has caused sweeping layoffs or cuts to work hours and, as a result, has squeezed personal budgets tighter than before. This, coupled with the already patchwork of coverage in our healthcare systems, means that people will continue to fall through the cracks.
Many other countries already subsidize universal access to contraception, in full or in part, including the UK, France, Spain, Sweden, Denmark, the Netherlands, Italy and Germany. These countries have done so because the personal, public health, and social benefits far outstrip the costs.
From a budget standpoint, programs that offer free prescription contraception have consistently proven to be revenue positive. This is because the cost of providing free prescription contraception is considerably lower than the costs associated with unintended pregnancy.
A 2015 study in the Canadian Medical Association Journal estimated that the cost of a national program offering people no-cost prescription contraception would cost $157 million, but result in $320 million in savings from direct medical costs alone. In this way, a national program would save as much as $163 million in direct medical costs - this study did not account for savings in other areas of social spending (source; source). In a separate BC-focused study, Options for Sexual Health estimated that every $1 spent on contraceptive support can save as much as $90 in public expenditure on social supports.
The provision of universal no-cost prescription contraception also contributes significantly to normalizing sexual and reproductive health, and it does so in a number of ways. First, we are fortunate in Canada to have mandated sexual health education in schools. A key component of many of these programs is educating young people about the risks and harms associated with unintended pregnancy and exposure to sexually transmitted infections (STIs). As Options for Sexual Health explains, “this emphasis arguably carries with it the duty to provide barrier-free access to protective and preventive clinical services and contraceptive products. This duty is implicitly acknowledged in the availability of free contraception in youth clinics sporadically around the province, so why are all youth not treated equitably?”
Providing young people with information about contraception, without the concomitant ability to equitably access it, fails to support young people in their efforts to responsibly apply this information to their own lives.
Lastly, and perhaps most obviously, access to prescription contraception is a gender equality issue. Reproductive options targeted towards men are easily accessible, low-cost, and often free. External condoms are available at every pharmacy and distributed for free in many community centres, health clinics, and schools. Vasectomy costs are covered by most provincial and territorial health plans. Contraception targeting women and people with uteruses is much more expensive and complicated, too often putting it out of reach.
To summarize, offering no-cost prescription contraception to all Canadians is:
Good social policy: removing all barriers to accessing contraception is a powerful affirmation of gender equality, and specifically of the right of all people to determine for themselves when and whether to become pregnant and bear children, a right supported in both federal and provincial arenas;
Good health policy: universal access to prescription contraception will improve health outcomes by reducing unintended pregnancies and their associated risks, particularly among adolescents, and will maximize the health benefits and outcomes of preparing for planned pregnancy. Moreover, not all prescription contraception is prescribed in order to prevent pregnancy, meaning this policy will also promote other related health benefits.
Good economic policy: the investment required to provide universal access to prescription contraceptives will yield significant returns in reduced public expenditures.
Good education policy: the availability of publicly-funded contraception will have a significant impact on normalizing the conversation about sexual and reproductive health and rights, and on increasing the likelihood that school sexual health curricula include comprehensive, factual and non-judgmental information on contraceptive use.
It is for these reasons, and others, that the Canadian Medical Association (2012), the Society of Obstetricians and Gynaecologists of Canada (2015), and the Canadian Paediatric Society (2019) have all called for universal access to contraceptives.
We therefore hope that you will include a policy of universal access to no-cost prescription contraception for all Canadians in the 2021 Budget.
The Organizing Committee of the AccessBC Campaign for free prescription contraception.