A woman is about to give birth. It will be her second child, and she's not looking to have a third anytime soon. She doesn't want to take birth control pills while she's breast-feeding. And condoms aren't as error-proof as she'd like.
There are a couple of alternatives that are safe, effective and could work for years: an IUD or an implant. She'll need a doctor to get those.
Here's the catch: Her Medicaid plan won't pay for contraception if she tries to get it while she's still at the hospital.
New York has just joined five other states in making it easier for our fictional mom to have access to the kind of family planning options she was seeking without worrying about the price tag.
At first glance this is a technical issue about Medicaid reimbursements. But it is also about postpartum contraception and which women have access to it.
There are a number of reasons why states would want women who have just given birth to have access to birth control. For one, waiting longer before having another baby is healthier. Plus, studies have shown that paying for birth control is cheaper in the long run.
The "bottom line priority" is to remove barriers to contraception, says Deborah Kaplan, New York City's assistant health commissioner.
A relatively small group of people is directly affected by the policy change announced by New York state and city health officials on July 17. It relates only to women in the Medicaid fee-for-service program who have just given birth.
With a fee-for-service plan, health care providers get money from Medicaid so that low-income people can get the care they need without the cost.
There are rules, of course, about what the plan will pay for. In most states, for example, Medicaid will not reimburse the doctor for delivering a baby and giving a woman an IUD in the same visit.
If the mom waits six weeks for a postpartum appointment, she can get an IUD and her doctor will get money from Medicaid.
But women are much less likely to get contraception at that point, says Kaplan.
So New York has changed its Medicaid reimbursement rules. Now, women with fee-for-service plans can get an IUD or implant immediately after giving birth.
IUDs and implants are not popular with women in the U.S., despite being among the most effective methods of birth control. Women's health advocates are trying to convince more women to consider them. With the Affordable Care Act, new insurance plans should fully cover these methods, though there are exceptions.
An IUD is a T-shaped piece of plastic that is put inside the uterus by a health care provider. One type of IUD releases hormones to prevent fertilization and another uses copper to fight off sperm. The kind with hormones can stay put for 3 to 5 years; the one with copper lasts for about 10.
The hormonal implant is a flexible rod about the size of a match that goes just under the skin in the upper arm (yes, you have to go to the doctor's office for this one, too). It also uses hormones to prevent pregnancy. It works for three years.
No daily reminders or regular pharmacy trips needed with these methods. If a woman decides she wants to have a baby, she can have a doctor take out the IUD or the implant at any time.
With hormonal birth control such as the pill, there are risks to consider — particularly for women who plan to breast-feed. But the hormone found in the IUD and the implant, progestin, is regarded as safe for women who are breast-feeding.
New York is not trying to imply that IUDs and implants are the best choice for everyone, Kaplan told Shots. But the state is trying to make a point.
"We want women to have the options," she says, "and then [work] with their provider to make the best decision with all the information available."
Kaplan says New York officials are hoping that this small policy decision will persuade other states and insurance providers to look at their coverage, too.
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