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Defunding Planned Parenthood-The Stakes for America's Women.

As part of the Republican plan to repeal and replace the Affordable Care Act, Planned Parenthood would be banned from access to Medicaid reimbursements and federal family-planning funds, thus losing more than $500 million in government funding per year,1 about two-fifths of its total revenue.2 People who are unfamiliar with past fights about reproductive rights in the United States may assume that this prohibition refers to abortions. Medicaid funds, however, already cannot be used for pregnancy termination unless the mother’s life is in danger. Rather, the Republican plan would prohibit Planned Parenthood from billing the federal government for contraception and other reproductive health care services, tests for sexually transmitted diseases, and primary care. My opposition to this ban comes from both personal and professional experience. When I was 22 years old and a student at Columbia University, I scheduled an appointment at the health center. I had become frustrated with using the pill as my contraceptive method. But I knew how important it was for my future and my health to not become pregnant. I had done my research. I knew there were other contraceptive options, such as intrauterine devices (IUD) and implantable devices, which together are referred to as long-acting reversible contraception. These forms of contraception are more than 99% effective, require a 1-time insertion, and last for years. There is no need for frequent trips to the pharmacy or taking a pill every day. For many women, the adverse effect profiles are more desirable than for birth control pills. For these reasons, long-acting reversible contraception is now considered the firstline contraceptive option for all women, starting with teenagers. Unfortunately, my visit to my college health center was disappointing. The clinician I saw was misinformed about the contraceptive options that were available for nulliparous women and was highly dismissive about my concerns regarding the pill. I left without making progress toward my goal of finding the contraception that would work best for me. Back in my dorm I did more research and made an appointment at Planned Parenthood in Greenwich Village in New York City. My experience there was nothing short of wonderful. The clinician was highly trained, warm, and took the time to educate me and prepare me for an IUD insertion procedure. I still think about her as a role model of empathy in my own work as a physician. With a $25 co-pay, I received a copper IUD. Eight years later I still have it. The impact of receiving an IUD on my health, wellbeing, and future cannot be overstated. Control over one’s own body is primary. Access to reliable contraception has enabled me to plan for my future. I went to medical school and am now an internal medical resident, with plans to work as a primary care physician after residency. My path would have been very different if I had unintentionally become pregnant. In the United States in 2011, 45% of pregnancies were unintended3—it happens often. Access to reproductive health care has also made a huge impact on the status of women in the United States. It is estimated that one-third of the wage gains that women have made since 1960 can be attributed to access to contraception. Access to birth control has been associated with women obtaining more years of higher education.4 It allows a woman to time pregnancies for a period of relative financial stability, thus decreasing the likelihood that she and her child will be and remain poor. Moreover, investing in contraception saves the government money, it is estimated that for every $1 the federal government spends on contraception, it saves $7.09, largely owing to the prevention of unintended pregnancy.5 This is a very favorable return on investment. Traditionally, primary care clinicians and obstetrician-gynecologists have shared responsibility for women’s health. Although some primary care clinicians are passionate about women’s health and have sufficient training and expertise to provide a full range of reproductive health services to their patients, others refer their patients. In the current political climate, there is a real possibility that many of the clinicians who have been providing women with reproductive health care will lose much of their funding. Primary care physicians should be prepared to step up for their patients. Through continuing medical education and other means, we should learn how to provide comprehensive care, including longacting reversible contraception. This may become a critical need. Planned Parenthood has 57 local affiliates that operate about 650 health centers across the United States. In 2015, the organization received $553 million in reimbursement and grants from the federal government, $309 million from private insurers, $353 million from donations, and $80 million from other sources.2 According to the organization, 2.5 million men and women in the United States visit the health centers each year, and an estimated 1 in 5 women has visited a center at least once in her life.6 Since the November 2016 federal elections, the president of Planned Parenthood reports a VIEWPOINT