Tuesday 5 February 2013

Contraception costs

Berk Ozler asks whether the government should provide free emergency contraception for young girls. It's an interesting question, especially as the Taranaki District Health Board recently announced plans for free EC provision.* Berk summarises the existing literature pretty comprehensively.

But I'll quibble a bit with his policy conclusion, at risk of channeling Steven Landsburg.

Berk and I agree entirely on his first conclusion: the morning after pill should be easily available without a prescription. It's safe, accidents (or worse) happen, and the barrier of going through a doctor can be non-trivial.

He then asks if it should be subsidised. Berk writes:
That question is more difficult. It depends on the future costs of teen pregnancy (and abortions) – both to the individual and to society. If children from single parent families, poorer families, etc. are more likely to need EC but less likely to be able to afford it, it may make sense for the government to subsidize the cost. Even if the costs are solely to the future adult herself and not to the society in general, they can be justified under the principle of ‘second chances’ – after all we’re talking about children and young people here. If there are positive externalities, the argument for subsidies is even simpler. So, I’ll return to the issue of subsidies after reviewing the literature on the individual consequences and public health externalities of making EC freely available to young people.
Berk's summary of the relevant literature:
  • "There is some reason to worry about children's outcomes in teen pregnancies" 
    • increased risk of poor natal outcomes

  • "The evidence on the effects of teen pregnancies on future outcomes of the mother are mixed. There is not enough here to justify a strong stance for a policy decision." 
    • Most of the effects you see in the cross section are due to that women having children in their teens tend to be different from those who decide to wait until they are older, and would have different outcomes even if they had not had children while young. 

  • There is little evidence that use of the morning after pill has any effect on teen pregnancy rates, abortion rates, or STD rates, though it does somewhat reduce condom use.
    • Berk here highlights that failure to use the emergency contraception even where provided may be a problem, perhaps due to "a failure to recognize (or acknowledge) a risk of conception on part of the prospective users." He writes:
      “In a survey of thousands of teenage mothers who had unintended pregnancies, about a third who didn’t use birth control said the reason was they didn’t believe they could get pregnant. Why they thought that isn’t clear.” The evidence is suggesting that (a) unprotected sexual activity is high among people who don’t report not wanting to have children; and (b) they don’t use the free EC that is in their drawer and can be used for up to 5 days after the unprotected sexual activity or a contraceptive incident. You can take a horse to the water, but you cannot make him drink… 
He concludes that though the public health effects may be negligible, emergency contraception should be available for young people and, ideally, free if we can afford it.

Ozler notes that the morning after pill costs $40 USD and that there's some evidence that teens substitute to its use from condoms (which are rather cheaper). If there's little evidence of other policy-relevant benefits from widespread subsidised EC availability, then I'm having an awfully hard time seeing why the government should stump up $40 per dose.** The NZ Family Planning website sells condoms for about $1.50 each.

I'm also pretty sure that  the government provides subsidised access to condoms via a doctor's prescription.

Steven Landsburgh controversially wondered last year why he should be paying for other peoples' birth control. I can see some decent second-best arguments for that the government subsidise birth control, not least of which is that it may partially offset the incentives created by governments' commitments to support children borne by those who cannot afford to raise them. The elasticity of birth rates among the improvident to subsidised childbearing may be rather larger than the elasticity with respect to the financial cost of contraception, but the former isn't much on the table aside from DPB work requirements. Whatever the second-best arguments for subsidised contraception, I have a hard time seeing the case for a general subsidy for a relatively expensive method of contraception.

* This follows on from a similar trial at the Auckland DHB. One of my projects for the coming semester is to get data from sexual health clinics on STD rates to see whether the Auckland trial had any effect on STDs. We'd started getting things lined up to get that data in the spring*** of 2010, and then the earthquakes put it rather far onto the backburner.

** If you want to subsidise the morning after pill for women seeing a doctor after sexual assault, I'm on your side. That's different from giving it for free to everybody.

*** Wow, North American habits die hard. First draft said fall. But it was August/September. And that's spring here.


  1. Ideally, the government would price discriminate based on the circumstances of the individual showing up at the clinic needing EBC, but the cost of that targeting/discrimination would be likely higher than the savings. So, because I am sensitive to inequalities of opportunity and I do think that infants/children are likely to suffer from being born to 13-14 year-olds (and the government may have to pick up the tab, as you correctly pointed out), I fall on the side of an indiscriminate subsidy. I think producing beneficiary cards, proving sexual assault, etc. are too costly and unnecessary burdens to access -- sometimes what one needs may be just an anonymous pill.

    Whether or not EBC reduces the likelihood of teen pregnancies and abortions in NZ is an open question (and should probably be rigorously evaluated), without which the subsidy is probably not necessary, but then also not at all costly...


  2. Where the government has decided that they want to subsidise things for poor people, they usually do it via the Community Services Card. So we already have beneficiary cards. We just tend not to give them to under-18s except in specific circumstances.

    If there's any reason to believe that this is just one instance of a broader class of problems - namely, kids of poor parents having a hard time getting access to medical services because they don't want to talk to their parents about getting the CSC - then isn't the better solution to reduce the age cut-off for getting the CSC?

  3. If socially and politically feasible and easily distributed, yes. I can see similar criticisms cropping up, though, this time with the parents potentially joining in with objections as well -- that might be too much of a hassle for the policymaker, who may just decide to quietly pay more for the problem than reduce trust in the system, etc.

  4. I'm not sure whether parents would object more to the government giving their kids free contraceptives or a card giving them access to free contraceptives and to other medical services. I suspect the former, because it can't be packaged as "this lets them get to the doctor more easily when they need to and you don't have time", although the negative tradeoff could well be that you'd want the parents attending with the kid most of the time.

    It can be simultaneously true that EBC costs a lot while doing little to prevent pregnancy or abortions: all that's required is enough kids flipping over from condoms to EBC. I don't know how many would do that though relative to the number who'd use it for unplanned emergencies.

  5. All good points, many of which are empirical questions...