Free Viagra but no birth control? Here's how that works out economically

“There is, perhaps, one invention that historians a thousand years in the future will look back on and say: that defined the 20th century,” The Economist wrote in 1999. “That invention is the contraceptive pill.”

To some, this might sound like hyperbole. After all, the 1900s gave us such life-changing innovations as the world wide web, microprocessors and airplanes. But to think that way would be to vastly underestimate how much this tiny pill has changed the modern world.

By allowing women to choose if and when they would have children, the contraceptive pill ushered in a cultural, gender and economic revolution. But now that revolution is at risk of stalling. Thanks to a change of policy, it just became a lot more difficult for women in the US to access this miracle drug.

It’s hard to wrap your head around these latest developments without at least a basic understanding of the US healthcare system, and in particular the changes it has undergone in recent years.

Because group policies tend to be more affordable than individual ones, the majority of Americans get their health insurance through their employer. This means that the level of coverage someone receives very much depends on their company’s generosity.

Until relatively recently, many companies chose not to cover birth control, meaning that women generally faced higher out-of-pocket health costs than men. In 1998, for example, only 33% of large group health plans covered oral contraception. That same year, when the male impotence drug Viagra hit the market, more than 50% of prescriptions received coverage.

The Affordable Care Act – also known as Obamacare – changed that, requiring insurance companies to cover all FDA-approved contraception. There were a few exceptions – churches and some religious groups, for example – but the impact was still enormous. Within two years, the share of women paying for oral contraception fell from almost 21% to 3.6%.

This month, those exceptions became much broader. In keeping with a campaign pledge, the Trump administration announced that any company with “sincerely held religious beliefs or moral convictions” can refuse to cover contraception. This means that 55 million American women who currently have access to free birth control risk losing their coverage.

While the administration's announcement was heavy on spiritual and moral references, many deeply religious nations do understand the economic importance of access to birth control.

For example, the Philippines – the world’s third-largest Roman Catholic nation – has committed to providing universal modern family planning by 2018. The pledge is part of a larger government push to eradicate poverty.

Indeed, research suggests that these two things – family planning and poverty – are inextricably linked. At the most basic level, when governments limit access to birth control, it’s poorer women who bear the brunt. That’s what experts fear will now happen in the US. “More affluent women will be able to pay out of pocket,” Martha J. Bailey explains. As a professor of economics, she has spent years studying the socio-economic impact of access to contraception.

And for those who can’t afford the added cost? “Research suggests that unintended pregnancies will increase," Bailey points out. "It’s hard to say by how much, but we know what happens as a result. In 2011, 42% of unintended pregnancies ended in abortion.”

The relationship between poverty and family planning runs even deeper, though. All the research points to the fact that reliable, affordable birth control helps empower women economically. In 2005, for example, the economist Heinrich Hock found that between 1969 and 1980, women in the US with access to oral contraception were more likely to enroll in higher education and 35% less likely to drop out.

Those same women then went on to better and higher-paying jobs than those available to their mothers. Research from Bailey and two colleagues, Brad Hershbein and Amalia R. Miller, estimates that the pill accounted for 10% of the narrowing of the gender gap in the 1980s and 30% in the 1990s.

“The pill’s power to transform childbearing from probabilistic to planned shifted women’s career decisions and compensation for decades to come,” the authors concluded.

Why does any of this matter? Well for one thing, as the latest Global Gender Gap Report points out, there is the issue of fairness. “There is a fundamental moral case for empowering women: women represent one half of the global population and it is self-evident that they must have equal access to health, education and earning power,” the report states.

But even if you don’t believe that women’s educational and economic empowerment is important, family planning programmes still make sense. That’s because the positive effects aren’t just felt by individuals. In fact, families, communities and even countries benefit.

“Malthusianism, one of the oldest models in economics, showed how childbearing can affect the entire economy. This is still true today: the costs of unintended pregnancies affect us all,” Bailey says. “Family planning programmes raise parental incomes and reduce the incidence of child poverty and government expenditures on public assistance.”

What’s next for women in the US affected by this change of policy? Kitty Kolbert, a former reproductive rights attorney, thinks government, business and citizens each have a role to play.

“​More pro-choice women in elected office and in key leadership roles across government and business is important,” she says. “But equally important is for families to register their displeasure openly and vigorously when companies and politicians deny them access to these important drugs and devices.”

Whatever happens, Bailey is sure of one thing: women in America aren’t going down without a fight. “I think putting the genie back in the bottle is going to be hard," she adds. "Women won’t give up their progress lightly.”