The Trump administration recently rolled back rules that required employers to provide coverage for contraception in their health insurance plans. Now, employers who object to providing contraceptive coverage because it conflicts with their sincerely held religious or moral beliefs will be exempt from doing so.

Prior to the rule change, which went into effect Friday, more than 62 million women had access to birth control without co-payments because of the Affordable Care Act‘s contraceptive coverage mandate. The number of women with out-of-pocket expenditures on contraceptives dropped from 21% to 3% once the ACA mandate was established, according to the most recent data from the Kaiser Family Foundation.

Under the new regulations, hundreds of thousands of women could lose birth control coverage benefits they now receive, which could mean they have to pay higher out-of-pocket costs for contraception.

“This is a step back,” said Dr. Janet Realini, the founder and associate vice president of the nonprofit Healthy Futures of Texas, which works to reduce teen and unplanned pregnancy in San Antonio and across Texas. “How far [of] a step back remains to be seen.”

In Texas, where maternal mortality and teen pregnancy rates are higher than the nation as a whole, changes in contraceptive coverage will impact women’s health, said Kori Eberle, program manager at the City’s Healthy Start program, which supports at-risk mothers and their babies. “You’re going to have an increase in unplanned and at-risk pregnancies, which put both mom and baby at risk.”

Bexar County women and teens have benefited from increased access to birth control, with teen pregnancy rates falling 47% from 2000-2013. National researchers and healthcare professionals point to increased access and use of contraceptives as an important factor leading to the decline in teen pregnancy.

However, even with the decline, the county’s rate still hovered at 55%, higher than the national average.

In 2010, the first year of health insurance coverage through the ACA, the teen birth rate was 50.6 births per 1,000 in Bexar County. In 2016, there were 20.3 births occurring per 1,000 teenage women aged 15-19 – a historic low for the city, which has researchers  pointing to contraceptives as a contributing factor.

In a global analysis of 172 countries, the Bloomberg School of Public Health at Johns Hopkins University found that increased access to birth control significantly decreased maternal mortality. The researchers estimate that in the absence of contraceptive use. the number of maternal deaths would be almost 266,000 higher than the current level.

Even under the ACA, Texas’ Maternal Mortality and Morbidity Task Force found that the rate of pregnancy-related deaths in Texas has nearly doubled since 2010. Between 2011 and 2012, 189 Texas mothers died within one year of giving birth.

Bexar County has identified maternal and child mortality as one of its community health priorities for the Metro Health Strategic Plan for 2017-2019.

Metro Health Director Colleen Bridger said that the contraceptive mandate was created “in the spirit of things that help from a preventive health perspective,” and compared the availability of contraceptives to mammograms: Just because they are covered as a preventive health measure doesn’t mean that they are required.  

“[The mandate wasn’t] saying that everyone has to use birth control,” Bridger said. “It said that all employers have to offer it to those who want to use it as a form of preventive health.”

Women use birth control for a variety of reasons beyond preventing unwanted pregnancy. A Guttmacher Institute report on contraceptives found that 58% of women who use birth control pills cite non-contraceptive reasons for doing so. Of these, 31% use it to prevent or treat menstrual cramps, 28% to regulate their menstrual cycle, 14% to treat acne, and 4% for endometriosis.

Aimee, 32, is a San Antonio resident who was diagnosed with polycystic ovary syndrome (PCOS) in her teens after struggling with irregular menstrual cycles. Oral contraceptives are often prescribed to manage the symptoms.

Aimee told the Rivard Report that since being diagnosed with PCOS, oral contraceptives have varied in affordability. Before the ACA, she paid anywhere from $9 to $55 and recalled several instances in which she could not afford the pills.

While the retail cost of oral contraceptives generally is less than $50, the out-of-pocket cost for contraception such as an intrauterine device (IUD) may cost a patient up to $1,000.

Realini said that while some people might argue that birth control is not costly, that is “just not the case.” To get a prescription, women have to visit a doctor and/or a pharmacy, which costs both time and money. Before the ACA was put into law, “somewhere around one-third to half of women had trouble paying for birth control in this country,” she said.

Realini said that the change in the federal mandate is driven by a lack of information about contraception and its impact on women’s reproductive health.

“The widespread misunderstanding of how it works, that it’s different than abortion, [and the false notion] that it pushes men or women to have more sex – all those misunderstandings about those truths means that in our popular culture there’s a great vulnerability for women working for employers who don’t have all of the information,” Realini said.

Aimee, who asked to be identified by first name only, is a Protestant Christian and considers herself active in her faith. “I’m pro-life. I don’t view taking birth control as an abortion,” she said.

Realini said that while birth control is often viewed as politically and ethically divisive, people across political parties tend to agree that it is both helpful and necessary.

“In reality, polls show clearly that it is not controversial,” Realini said. “Republicans and Democrats support birth control. Catholic women use birth control to the [same] extent that non-Catholic women use it.

But for employers who object to contraception on moral or religious grounds, the ACA rule change was overdue, said Cardinal Daniel N. DiNardo, archbishop of Galveston-Houston and president of the United States Conference of Catholic Bishops. DiNardo recently wrote an opinion column in The Hill in which he explained why he supported ending the contraception mandate.

“Immunity from government coercion is a right that all citizens in this country should enjoy,” DiNardo wrote. “So in asking for an exemption to the HHS mandate to fully accommodate deeply held moral and religious beliefs, we are simply asking that the government give us the space to fully participate in American life.”

The requirement to provide contraception coverage has long been opposed by religious groups and has been wrapped up in litigation for more than five years. The Trump administration said the decision to end the mandate was made to protect people from being forced to violate their religious beliefs, and downplayed concerns that more women would struggle to afford birth control.

“The United States has a long history of providing conscience protections in the regulation of health care for entities and individuals with objections based on religious beliefs or moral convictions,” the administration wrote in the Federal Register.

Roseanna Garza reports on health and bioscience for the San Antonio Report.