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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.

You can think of the health insurance product as two pieces that are purchased together. One is coverage for health risks, that is illnesses. This is what you're thinking of as "insurance". The second part is that you're purchasing a bundle of preventative care, like annual checkups, vaccinations and birth control.

Preventative care reduces the cost of illness, therefore the insurance company, and the law, reasonably requires that you buy both together. In the specific example, birth control is cheaper than an abortion.

It is not uncommon for insurance products to bundle a risk and a non-risk component together. One example is whole-life insurance. You get paid either if you die, or you don't die before the policy's maturity date. Logically, you will always get paid. You can see the policy as a combination of an investment, which pays at the maturity date, and a risk portion, which pays extra if you die before maturity.

Other examples of bundled preventative services occur in commercial insurance. For example, factory insurance often includes on-site audits and safety support by the insurer. Auto insurance companies will also sponsor safe driving classes for their policyholders.

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).

Health insurance, like any other insurance, is about pooling groups together to spread out the risk of a catastrophic event. Why wouldn't someone just pay directly for something, and why does insurance cover it? Because what is being covered is the entire spectrum of services and protection against something significant. It's that protection that is key to insurance.

Why do you pay premiums for homeowners insurance? My house will probably never burn down. It will probably never be hit by a tornado. And yet, people like me pay hundreds or thousands of dollars to an insurance company for something I will probably never need in my lifetime. However, if I do need it, I can't afford to pay it out of pocket. So, insurance bands together groups of people, all willing to pool their money and their collective risk, so they are protected IF an event happens where they need that protection.

With health insurance, it's the same thing, except it's not just catastrophic events that are covered. As a company that has to deal with financial arrangements with healthcare providers, it's more convenient and efficient to pay for the service of having the whole spectrum of health care needs covered.

One year, I might just come in for my annual physical and associated blood labs. My premiums that I pay cover way more than that. Another year, I might fall on the ice, and when I heal, accidentally have a piano dropped on me.

While I can afford to pay regular monthly premiums that add up to much more than I'd need in a non-eventful year, I could not afford the financial hit that one or more major events would cost for me, out of pocket. So, like with homeowners insurance, I'm part of a group paying in more than I would typically use, for most of my lifetime, for the security and protection of having that pool of resources available for me should something bad happen or I incur larger expenses during other parts of my life.
Health insurance covers preventative physicals and screenings. Why? Why don't they just pay when bad things happen? Because if they pay for a dozens of $300 screenings and are able to catch and prevent a $20,000 event from happening later, when it is more serious and expensive to treat, then they have just saved money.

Drugs are part of treatment. I may have blood clots and need prescription blood thinners. This would be, clearly, part of "something happened to me, and I need treatment." But drug coverage can also be for that preventative aspect. Doctor says "take a half-aspirin a day" - now, that's something easily available over the counter, but perhaps, to encourage me to take the preventative drugs, they state they will cover the cost if the doctor has it dispensed from a pharmacy. That's a more expensive way to do it, overall, vs just buying aspirin from the grocery store, but by making it "free," there's a higher likelihood that I will do it, I will take it, and then I won't have to take the much more expensive treatment drugs later on, for chunky blood.

By the same token, if someone does not necessarily want to have a child, but will go ahead and carry it to term and raise that child, then you are looking at $100 a month for contraception versus $15K to $20K for actual childbirth, with additional pre-natal costs and screenings, and then a lifetime of healthcare expenses for a whole other human being. By avoiding that unwanted pregnancy the system is saving hundreds of thousands of dollars of medical expenses that the shared pool would have to pay for. Volunteering to cover the cost of the preventative treatment (contraception) makes fiscal sense.

While in school, I studied a little bit of actuarial science. This answer is based entirely on my exposure there.

Insurance is based on the idea of an insurable event. In many cases this is intuitive - your home owner's insurance covers things like a tornado. In the case of a pharmacy benefit, the insurable event is the prescription claim. The insurance company has a statistical model which predicts what the total pharmacy claims for a group of insured people are likely to be.

It doesn't really matter that birth control is taken to deter pregnancy. You aren't being insured against pregnancy, you are being insured against the loss of paying a pharmacy bill.

For more information on the basic mathematics behind insurance, check out the Society of Actuaries document 'Risk and Insurance'. It's the basis behind their introductory exam.

There's different models in the US but much of this still applies (it does in every other industrialized country):

Vision insurance covers you for eye exams. Not just after your friend throws a dart into your eyeball but every year.

Dental insurance covers routine preventive exams. Not just after your friend punches out one of your teeth (you should consider getting better friends, there seems to be a pattern evolving).

Health insurance should cover things like birth control and other preventive care. They should cover exams to see if children develop as expected. They should cover vaccines. All of this is in their best interest.

Should my homeowner's insurance cover preventive treatment for termites ? Yes. It's in their best interest. Should your car insurance pay for you getting a safer car ? Yes. (and they do by giving you a lower rate).

In this case, we have "in the event of ____, the insurance company pays me for birth control". I don't see anything logical that can go into the first blank space.

It may be, "In the event of a doctor giving me a prescription for something, which I'd have to pay for if I didn't have insurance".

Perhaps you pay a certain fixed, yearly amount of insurance premium, and in return the insurance company pays for all your prescriptions. The actual cost of the prescriptions might be more or less than the premium.

Perhaps most people pay more in premiums than they get back as reimbursements, even so the insurance company pays for whatever little they are prescribed.