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(Not sure if this is the right Stack Exchange site. I'm asking it here because the event in question, as well as the repercussions, are political in nature.)

Wikipedia's article on Sandra Fluke includes a section about her testifying before Congress on whether "religiously affiliated institutions such as universities and hospitals should provide insurance plans that cover all costs for medicinal contraceptives."

I don't understand how insurance works with birth control. My picture of how insurance works is, I pay the insurance provider a certain amount of money. In return, the insurance provider promises that if something untoward happens to me (e.g. I'm knocked down by a car), they'll pay for my treatment. The cost of the insurance depends on what I want coverage for (e.g. do I want coverage for developing skin cancer?) and any associated risk factors (e.g. do I have any family history of skin cancer?).

How does this model work for birth control? Birth control works best if taken before the event, not after. It doesn't sound like something insurance works for because there's nothing to cover. Instead of paying the insurance company to cover all costs for contraceptives, I should logically simply buy the contraceptives from a pharmacist.

The only scenario I can see in which this would work would be, I pay the insurance provider such that in the event I conceive, they'll pay for me to terminate the pregnancy. However, this doesn't seem like what Sandra Fluke was talking about.

TL;DR The customer pays the insurance provider money. Then the insurance provider allows the customer to spend this money on birth control, be it pills or more invasive medical procedures.

Health insurance benefits

My picture of how insurance works is, I pay the insurance provider a certain amount of money. In return, the insurance provider promises that if something untoward happens to me (e.g. I'm knocked down by a car), they'll pay for my treatment.

That's one possible way for insurance to work. Typically, when it comes to health insurance customers expect it to cover other types of medical expenditures: screening, counseling, vaccination, pregnancy and newborn care, etc. Emergency coverage is only a part of the insurance policy.

Insurance providers usually follow the market and provide a wide array of health care benefits. Some plans might cover massage therapy, gym membership, and nutrition counseling.

Essential health benefits

HealthCare.gov has a page on essential health benefits that must be provided under ACA (What Marketplace health insurance plans cover):

Every health plan must cover the following services:

• Ambulatory patient services (outpatient care you get without being admitted to a hospital)


• Emergency services


• Hospitalization (like surgery and overnight stays)


• Pregnancy, maternity, and newborn care (both before and after birth)


• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)


• Prescription drugs


• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)


• Laboratory services


• Preventive and wellness services and chronic disease management


• Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

As you can see, most of the mandated coverage is not directly related to emergency services. Preventive care alone includes an extensive set of procedures

Birth control mandate

Birth control is listed under "Additional benefits":

Additional benefits

Plans must also include the following benefits:

• Birth control coverage


• Breastfeeding coverage

Under the ACA, at least one form of 18 FDA-approved methods of birth control for women must be covered. Contraceptive methods include birth control pills, preventive barriers, emergency contraception, and sterilization procedures.

Sandra Fluke 2012 testimony

In her testimony, Sandra Fluke raised multiple arguments in favor of forcing insurance providers (in particular religious institutions) to cover the cost of medicinal contraceptives for women. Here're some of them:

• Without insurance, women with low income can't afford the cost of contraception.

Without insurance coverage, contraception can cost a woman over $3,000 during
law school. For a lot of students who, like me, are on public interest scholarships,
that’s practically an entire summer’s salary. ... Women ... have no
choice but to go without contraception.

• Women need contraceptive medication for other medical purposes and the blanket refusal to cover contraceptives is dangerous.

A friend of mine, for example, has polycystic ovarian syndrome
and has to take prescription birth control to stop cysts from growing on her ovaries.
Her prescription is technically covered by Georgetown insurance because it’s not
intended to prevent pregnancy. Under many religious institutions’ insurance plans,
it wouldn’t be, ...

In sixty-five percent of cases, our female students were interrogated by insurance
representatives and university medical staff about why they needed these
prescriptions and whether they were lying about their symptoms. For my friend,
and 20% of women in her situation, she never got the insurance company to cover
her prescription, despite verification of her illness from her doctor. Her claim was
denied repeatedly on the assumption that she really wanted the birth control to
prevent pregnancy. ...

... Now, in addition to potentially facing the health complications that
come with having menopause at an early age-- increased risk of cancer, heart
disease, and osteoporosis, she may never be able to conceive a child.

• Allowing insurance providers not to cover contraception sends a wrong message about the importance of female health.

This is the message that not requiring coverage of contraception sends. A
woman’s reproductive healthcare isn’t a necessity, isn’t a priority. One student
told us that she knew birth control wasn’t covered, and she assumed that’s how
Georgetown’s insurance handled all of women’s sexual healthcare, so when she
was raped, she didn’t go to the doctor even to be examined or tested for sexually
transmitted infections because she thought insurance wasn’t going to cover
something like that, something that was related to a woman’s reproductive health.

Her full statement is published on ABC news website.

Answers to specific questions

So, to answer your questions about birth control.

Birth control works best if taken before the event, not after.

In ACA's case, birth control is a set of medical services that includes emergency contraception.

It doesn't sound like something insurance works for because there's nothing to cover.

Health insurance usually includes preventive measures.

Instead of paying the insurance company to cover all costs for contraceptives, I should logically simply buy the contraceptives from a pharmacist.

In many cases, people are already paying for insurance anyway. The choice is then between spending additional money on the contraceptives and using insurance coverage. Some people won't be able to afford contraceptives. Some other people will choose to save money on them. Both cases will lead to an increased number of unwanted pregnancies with all the attendant consequences.

It seems like the core of your question comes down to a misunderstanding about how insurance works in the US. I'm going to make the assumption that you come from a country where basic medical care is covered by the government and insurance is used primarily as backup for extra costs incurred beyond that.

In the US, on the other hand, private insurance (for those who have it) is at the center of all health care. The expectation is that every healthcare expense (except for those that are excluded by the insurance companies) is run through insurance: from routine doctors visits, to prescription drugs, to ER visits or surgery. When you go to a pharmacy to buy contraceptives, the pharmacy bills the insurance company and charges you the specified copay (if applicable), just like with any other drug.

Therefore, you shouldn't be thinking of US health insurance as being similar to car insurance but as being similar to a privately run NHS.

It's in the insurance company's best interest to encourage any behavior which reduces further payouts. That's why they cover preventative measures, like screenings, wellness visits, etc. Birth control may cost the insurance company some money, but consider all the costs if birth control is not used and the person covered becomes pregnant - potentially all the costs of pregnancy, all the costs of birth, and then all the costs of the child growing up (who is family, and would be covered by that insurance) and kids are very expensive, medically. At best the insurance company could hope they'd only have to pay for an abortion, which is still expensive. In a way, you can consider covering birth control to be insurance for the insurance company (as well as for the person covered, who would also see significant cost increases with a pregnancy).