The patient was giddy with both nerves and happiness. The first thing she told me was that it had taken her a full year to get to this point—the day that we were going to insert her copper IUD. A number of months ago, she had briefly gotten insurance through her husband’s job, which had enabled her to get the IUD itself. But the co-pay for the primary care physician and then the insertion fees billed by the ob/gyn had been prohibitively expensive. She had to cancel the procedure. So here she was, one year later, finally pulling herself up the few steep stairs into the mobile health center parked off the side of a highway in North Miami.
I held her hand as I explained the procedure to her, like I had done with dozens of patients before her. I answered her questions. How likely is it that I could get pregnant, even with an IUD? How likely is that the IUD will fall out after it is inserted? Now that I have an IUD, is there anything that I can’t do? It was the first time that I had inserted an IUD while surrounded by the honking horns and street noises the easily permeated the walls of the mobile health center. The patient and I breathed deeply together, as I willed myself not to drop the device that it had taken her a year to obtain.
If I dropped the IUD, I could not insert it into the patient’s uterus; and I knew that she would have no way to obtain another one. The device—and the year of persistence it had taken her to finally get it—would have been wasted. The procedure, as usual, took about fifteen minutes. As I was finishing, I congratulated the patient. Congratulations! You’re not having a baby. She laughed, hugged me, and thanked me. She paused as she was leaving the mobile health center into the hot Miami sun: “Thank you! Thank you! This is going to change my life.”
I was reminded that patients are more grateful for long-acting contraception than for any other medical care that I provide.
There should be nothing remarkable about this patient interaction, but everything about it was exceptional. The Affordable Care Act has ensured access to contraception for patients who obtain coverage through the health insurance exchanges or through expanded Medicaid. But this does not help my patients. They are undocumented. They are uninsured. They fall into Florida’s deep Medicaid coverage gap. They are unable to get to Planned Parenthood. They are unable to afford co-pays for doctor’s visits or medications, including contraception.
This patient’s IUD was the first of about 20 devices that I’ve inserted for my clinic’s patients over the past year. We were lucky enough to find funding that allows us to cover the costs of long-acting reversible contraception for our patients. Luck, here, meant that I knew someone who is both wealthy and generous. He said yes when I asked for a small grant. Now, I have options besides birth control pills that I can reliably offer my patients. And often the monthly co-payments for birth control pills are too expensive, stressful, and simply not possible.
Women are forced to make the very real, unfair choice between feeding their children and paying for their contraception. IUDs are an excellent form of birth control for all women—but, often, particularly for those who are uninsured. Once inserted, they are over 99 percent effective at preventing pregnancy. There is no monthly associated cost or co-pay. But there are few patient-assistance programs, which cover the cost of obtaining the device itself. So birth control options remain terribly limited for women who are uninsured in this country.
Free clinics, like the mobile health center where I work, provide the ultimate safety net for marginalized and vulnerable patients, families and communities. I work in a state that chose not to expand Medicaid coverage through the Affordable Care Act. I also work in a state with the highest number of Obamacare enrollees in the country. I fear that, as President Trump continues to derail access to affordable care—and particularly access to reproductive health care—for millions of women, more and more doctors like me will feel like they are practicing in Florida. As a primary care physician dedicated to the care of all patients—documented and undocumented, insured and uninsured—I see reproductive health care as an absolute necessity and human right. So I love the mobile health center that allows me to see everyone, and my patients who are so desperate to maintain control over their own bodies.
