Universal contraceptive coverage curbs out-of-pocket (OOP) costs in British Columbia, especially for young people, new research shows.

British Columbia introduced a first-in-Canada policy in April 2023 that made contraception available for free to all residents. Before that point, contraception had been covered by a mix of private prescription drug insurance that was mainly employer-based; income-based public coverage, where the public system paid for prescriptions after an income-based annual deductible was reached; and OOP payments by patients, explained Elizabeth Nethery, PhD, a postdoctoral research fellow, and Laura Schummers, ScD, assistant professor of health outcomes, both at the University of British Columbia in Vancouver.

“There was substantial policy debate surrounding the importance of cost as a barrier to contraception use,” Nethery and Schummers told Medscape News Canada. In this study, they aimed to answer this question by examining who was paying for contraception before and after the policy and how much they were paying.

“The immediacy and the magnitude of the change [after implementation of the policy] were surprising,” they said. “We expected costs to patients to drop; that’s what the policy was designed to do. But this policy really worked: OOP spending fell by 83% in just 2 years. And when we look only at contraceptives that were fully covered [by formularies], costs dropped by 99%.”

The investigators also saw a clear effect of this policy in young people who were paying the most OOP before the policy was enacted. The finding highlighted how this group is not well served by the current mix of public and private drug plans in most Canadian provinces, especially when it comes to contraceptive access.

The study was published on May 29 in JAMA Health Forum.

‘Highly Effective’

Researchers conducted a controlled interrupted time-series analysis that examined aggregate monthly contraceptive prescription data, with British Columbia as the intervention province and a control modeled using other provinces. The analysis included all contraceptives dispensed to reproductive-aged females (ages, 15-49 years) in 10 Canadian provinces between April 2021 and March 2025 (ie, 2 years before and 2 years after the policy’s implementation).

The main outcome was the monthly proportion of contraception dispensed and estimated costs (in CAD), stratified by age, majority payer type, and contraception type.

During the 48-month study period, close to 2.8 million contraceptive prescriptions were dispensed, about half before the policy implementation and half after. In the pre-policy period, 38.7% of those prescriptions were paid OOP, 49.2% by private insurance, and 12.0% by public insurance.

“That’s more than double the rate we typically see for OOP for other prescription medications in Canada,” Nethery and Schummers said. “This [finding] highlighted that contraception was falling through the cracks in the patchwork pre-policy drug coverage structure.”

The highest pre-policy OOP share (44.6%) was for individuals aged 20-29 years, who also had the highest pre-policy costs. Once the policy was introduced, the OOP share immediately decreased by 24.9 percentage points overall.

By 2 years post-policy implementation, 9.6% of contraceptives in British Columbia were paid OOP, 81.7% by public insurance, and 8.7% by private insurance. When looking only at on-formulary contraceptives, 5.3% were paid OOP, whereas 3.3% of fully covered on-formulary contraceptives were paid OOP.

In fiscal year 2024-2025, total OOP spending per capita for contraceptives in British Columbia was $8 lower overall than that in the control provinces. The spending reduction was $7 per year for those aged 15-19 years, $11 per year for those aged 20-29 years, $7 per year for those aged 30-39 years, and $6 per year for those aged 40-49 years. This finding represented a per-user change of -$43 (-$42 on-formulary) per contraceptive year.

Study limitations included the restriction to average dispensation costs (eg, excluding clinician insertion fees and consultation charges) and contemporaneous price changes, such as the introduction of a new generic oral contraceptive in September 2023. The authors also were unable to evaluate nonprescription contraceptives (eg, condoms), downstream reproductive health service costs, or equity measures beyond age.

Nevertheless, they concluded, “The findings suggest that universal, first-dollar contraceptive coverage mandates are a highly effective policy measure to improve access to contraceptives, especially for young adults who often lack comprehensive drug insurance coverage.”

Recommending What’s Best

The findings have implications for clinicians and policymakers, Nethery and Schummers said. “When cost is no longer a barrier, the conversation between a clinician and a patient changes. Instead of recommending what’s affordable, clinicians can recommend what’s best. For contraception, that could mean more conversations about long-acting methods, intrauterine devices, and implants, which are the most effective but historically had the highest up-front costs. And patients are now free to choose whichever method feels right for them, irrespective of cost.”

At the policy level, they added, “this is an investment by the public system. As for why other provinces haven’t followed, there’s always hesitation around public spending investments, even when the evidence is strong. The federal pharmacare framework, while now law, still requires bilateral agreements with each province which have not yet been signed. What’s needed now is political will.”

Elizabeth K. Darling, PhD, assistant dean of midwifery at McMaster University in Hamilton, Ontario, agreed, noting, “The study is useful because it was able to quantify whether the policy worked the way that we expected it would and to look at the size of its impact. It’s valuable for policymakers to have real numbers that they can look at and work with.”

Making the best kind of contraception available to people without making them pay more “saves the healthcare system money because we avoid people having abortion care or having pregnancy care if they end up continuing with an unplanned pregnancy,” Darling, who was not involved in the study, told Medscape News Canada.

As for wider implementation across Canada, she noted that priorities vary across provincial governments. “Some governments pay attention to healthcare issues,” she said. “But this is what would typically be thought of as a women’s healthcare issue, and that’s not as high on the agenda for some governments as for others.

“One of the valuable pieces of this research is that we now have documentation that if you implement this policy as a government, there will be a net savings,” she said. “That’s a way to convince governments that might not care so much about women’s health issues but that do care about their bottom line.”

This project was supported by a Canadian Institutes of Health Research (CIHR) Catalyst Grant: Policy Research for Health System Transformation, Project Grant - Priority Announcement: Sex and Gender in Health Research, and CIHR Institute of Gender and Health. Nethery reported receiving grants from the CIHR and Health Research BC during the study. Schummers reported receiving grants from the CIHR during the study; grants from the CIHR, Canada Foundation for Innovation, and Women’s Health Research Institute outside the submitted work; and personal fees from O’Brien Institute for Public Health, Canada’s Drug Agency, and Canadian Society of Hospital Pharmacists outside the submitted work. Darling reported having no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDEdge, The Lancet (where she was a contributing editor), and Reuters Health.