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[UPDATED on Nov. 22]

KHN correspondent Shefali Luthra is reporting from Germany as a 2019 Arthur F. Burns Fellow.

HAMBURG, Germany — In the five years she’s lived in Germany, Erin Duffin doesn’t think she has paid more than 16 euros for medical care. Until now, that is.

Duffin, a 27-year-old American expat in Hamburg, has had an intrauterine device since she was 22. She got it before moving here from Virginia, where her employer-sponsored health insurance covered its entire cost.

Now, she’s due for a replacement. And since she receives her health care through the German public insurance program, it’s going to cost her 350 euros. That’s about $385, and almost a quarter of her monthly take-home pay. She hopes to pay it off in installments.

Coverage of birth control highlights a key difference between the U.S. and German health care systems. Virtually everyone in Germany has health coverage, and most get it through a government-funded system. Cost sharing here is capped at no more than 2% of household income.

But even though a doctor’s prescription is required for most types of contraception, it is not classified by the public insurance program as a medical need. It’s considered a lifestyle decision. Therefore, consumers bear the entire cost.

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When asked about covering birth control, or treating it as preventive medicine, multiple medical experts and researchers said that, frankly, the idea hadn’t really occurred to them. The idea that birth control is an elective choice and that you pay for it yourself is culturally ingrained, they said — and since pregnancy isn’t an illness, the argument goes, covering contraception shouldn’t be part of the collective health project.

“I never, to be honest, thought about it as so weird that we don’t have it covered — because that’s what I grew up with, and how it’s always been,” said Dr. Katharina Schweidtmann, a German physician and consultant at the World Health Organization. “It’s not that big a discussion.”

It’s one of the rare ways in which American health coverage is more generous.

“I don’t make a whole lot of money,” Duffin said over coffee in Hamburg’s downtown. “It’s going to be an expense I have to figure.”

Duffin and her boyfriend even discussed whether the price meant they should abandon the IUD for another type of birth control, she said, but ultimately decided its medical benefits meant they could and should make the finances work. (IUDs are considered a highly effective means of preventing unwanted pregnancy.)

The issue resonates across the pond. The American contraceptive benefit is relatively new, and a political lightning rod. As part of the Affordable Care Act, health plans are required to cover preventive care at no cost — a provision that has been interpreted to include women’s birth control approved by the Food and Drug Administration.

Under President Donald Trump, the White House has sought to roll back the mandate, issuing rules to exempt employers with religious objections. In July, an appeals court blocked the effort. The White House hasn’t indicated if it will appeal.

Comparing the two nations’ approaches to birth control coverage highlights complex issues.

In the United States, research shows, the lack of copays have led to more women using oral contraception and IUDs.

Even without coverage, though, women in Germany are often able to pay for birth control. The fact that so much else is covered — such as prescription drugs, mental health services — and that out-of-pocket costs are capped makes it easier to absorb these costs, women’s health experts said.

But, interviews with German doctors and advocates suggested, there is still a burden for lower-income women.

Germany’s public health insurance, which covers 90% of people, covers birth control for women 22 and younger. After that, they’re mostly on their own. Some programs exist for low-income women, but they are far from universal.

The cost of the pill is about the same on both sides of the Atlantic. IUDs are much more expensive in the U.S., often north of $1,000.

Germany’s coverage decision is cultural, not economic, experts here said. Sex and much of reproductive health are seen as a private matter, and the government has not calculated what it would cost to cover contraception across the board.

“People here don’t want to pay for private things [for other people],” said Holger Pfaff, a medical sociologist at the University of Cologne. “Birth control? That’s lifestyle. If someone wants to have it, that’s their choice, but there’s no medical reason.”

Schweidtmann suggested this is part of a more conservative ethos in Germany when it comes to sexual health and talking about sex — a view other medical experts echoed. Meanwhile, the unintended pregnancy rate here is on the lower end, as is true of Germany’s birth rate overall.

Still, the policy is at odds with other European countries. France partially reimburses for birth control. The United Kingdom provides it without charge through the National Health Service. (Before 1989, the former country of East Germany also made contraception free, as part of a broader effort to reduce unintended pregnancies.)

The impact here is clear, said Dr. Helga Seyler, a gynecologist at Hamburg’s Family Planning Center, which serves low-income women. Often, she said, female patients will opt for a less expensive option — for instance, a copper rather than hormonal IUD — even when it is not the best choice for health reasons.

These patients, she said, tell her it is all they can afford.

Seyler’s clinic benefits from a project run by the Hamburg government and provides 200,000 euros per year to fund free family planning for low-income women. It’s nowhere near enough to meet the need, she said. Seyler estimates they turn away at least half of those seeking contraception, because of insufficient resources.

Three years ago, Pro Familia, a German family planning organization similar to Planned Parenthood, launched a government-funded program to give low-income adult women in certain areas free contraception. In the initiative’s evaluation — released this month — most of the beneficiaries interviewed said birth control would be unattainable without financial aid. Pro Familia is lobbying German officials to add a government-funded contraceptive benefit.

“We think that contraception is basic for the health of all people and contraception methods are essential for all,” said Regine Wlassitschau, a Pro Familia spokeswoman.

However, many experts doubt that the issue has much political support.

“Because it has historically developed like this, it’s difficult now to introduce this concept of women’s health and reproductive health as something that should be normal to be covered,” said Maria Wersig, a social work professor at the University of Applied Sciences in Dortmund, who researches reproductive rights in Germany.

Shefali Luthra is currently reporting from Germany as a 2019 Arthur F. Burns Fellow. The fellowship is an exchange program for German, American and Canadian journalists operated by the International Center for Journalists and the Internationale Journalisten-Programme.