pricing and public investment in family planning services, problems in the provider base for contraception, and general bureaucratic complexities. The next main section explores the proposition that many opportunities to provide contraceptive information and services are being missed.

Financial Barriers

As is the case for a wide variety of health care interventions (see, for example, Stoddard et al., 1994), insurance coverage affects access to contraception (Kirkman-Liff and Korenfeld, 1994). For example, in the 1993 NSW survey of more than 1,000 women aged 21–40 mentioned earlier, Sonenstein and colleagues (1994) found that whether or not a reproductive health visit had occurred was heavily influenced by the presence of health insurance and a regular source of care. Overall, 20 percent of the sample had not had a reproductive health visit in the past year; however, for those without a regular source of care, the figure was 39 percent; for those without health insurance altogether, the figure was 42 percent.

Private Insurance

With regard to private insurance, the 1988 NSFG revealed that, overall, private insurance does not lie behind most family planning visits. In that year, about 41 percent of all women who received family planning services reported paying for their most recent visit out of their own pockets. Another 17 percent said they used insurance with a copayment or deductible. Insurance completely covered only 25 percent of recent visits, and 7 percent of visits were covered by Medicaid. The remaining services were provided at no charge to the client (Kaeser and Richards, 1994).

This modest presence of private insurance as a financing source for contraceptive services is consistent with the historic traditions of private-sector health insurance coverage—providing coverage of surgical services but not covering preventive care. A 1994 study by The Alan Guttmacher Institute of the coverage of reproductive health services in various insurance and financing plans concluded that although 85 percent or more of typical private health insurance policies cover sterilization services and 66 percent cover abortion, coverage of reversible contraception was appreciably thinner. None of the five reversible methods included in the study—intrauterine devices (IUDs), diaphragms, hormonal implants and injectables (e.g., Norplant and Depo-Provera), and oral contraceptives—is routinely covered by more than 40 percent of typical plans. Furthermore, half of the large-group plans cover no methods at all, and only 15 percent cover all five. Notably, even though oral contraceptives, the most



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