Feds to Men: Buy Your Own Aspirin and Put It Between Your Knees

Men will be paying more for insurance than they have in the past, yet receiving fewer preventive services than women, under the ACA. Part one of a two-part series on the surprising sex discrimination under the U.S. Affordable Care Act.

For the first time ever, the U.S. government will expand access to preventive health services for women without requiring equivalent coverage for men. The U.S. Affordable Care Act (ACA), sometimes labeled by critics as “Obamacare,” will be rolled out using rules likely to deny men equal access to contraception, sterilization, sexually transmitted infection prevention, domestic violence screening and counseling, and even counseling for HIV-positive men.

U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius hailed these “historic guidelines,” emphasizing their gender-bias:

Previously, preventive services for women had been recommended one-by-one as part of guidelines targeted at men as well. As such, the HHS directed the independent Institute of Medicine [IOM] to, for the first time ever, conduct a scientific review and provide recommendations on specific preventive measures that meet women’s unique health needs and help keep women healthy.

The problem is that HHS went well beyond obstetrical, gynecological, maternal health and chronic disease services, adding preventive health services not unique or important only to women, Yet the services will be provided on a no-cost-sharing basis only to women.  Worse, men were already medically underserved compared to women for many of these services:

No-Cost Preventive Health Service

For Women

For Men

Contraception

        Y

     N

Sterilization

        Y

     N

Contraception Education and Counseling

        Y

     N

Sexually Transmitted Infection prevention counseling for all sexually active individuals

        Y

     N

Counseling for Persons who are HIV+

        Y

     N

Human Papillomavirus (HPV) Testing

        Y

     N

Domestic / Interpersonal Violence Screening and Counseling

        Y

     N

Well-Person Visits to obtain Preventive Services Listed Above

        Y

     N

Suicide Intervention / Prevention Services

        N

     N

HHS was contacted for this article and had no corrections to the table.

In a nutshell, women’s IUDs, contraceptive pills and implants,  tubal ligations and birth control counseling must be provided without co-pays, doctor’s visit charges, or deductibles, while insurance companies will be free to charge men for vasectomies and contraceptive counseling. Women will universally receive free counseling if they test HIV-positive, but HIV-positive men will not.  HPV can result in anal cancer and genital warts in men as well as cervical cancer in women, but no-cost HPV DNA testing will be added to free pap smears for women, while men pay for HPV tests or go without.  The Centers for Disease Control found that 28.5 percent of men—over 40 million men—experience rape, physical violence, or stalking by an intimate partner. Those men, unlike women, will first have to ask for help and then pay out of pocket to receive it.

In contrast, a mental health service that men disproportionately need, is not a preventive health service under this Act or HHS guidelines. Men commit suicide at a rate nearly four times that of women.  Young men are at particular risk: the National Institute of Mental Health reports that the suicide rate for young men during late adolescence is almost five times that of their female peers, and by their early twenties the rate rises to almost six to one.  Reminiscent of Anatole France’s remark about the majestic equality of the law, suicide prevention services are excluded from the ACA / HHS no-cost-sharing package for both women and men.

Does President Obama’s Healthcare Plan Prohibit or Require Sex Discrimination?

HHS based its decision on Section 2713 of the ACA, which prohibits cost sharing (co-pays, co-insurance, and deductibles) in four specific categories of preventive health, including preventive health services for women.   While many critics view the ACA as mere health insurance legislation, supporters argued it would put in place experimental approaches to lower the ruinous cost of American healthcare.

One such approach was an increased focus on removing access barriers to preventive medicine.  But rather than ordering a bottom-up analysis of what preventive services would yield net cost-cutting benefits to the overall system if patient co-pays and deductibles were removed, Congress reached for three, off-the-shelf, clinically-based lists of preventive services. The three lists are:  (1) recommendations of the U.S. Preventive Services Task Force (USPSTF), (2) immunization recommendations of the Centers for Disease Control (CDC), and (3) guidelines for pediatric preventive care supported by the Health Resources and Services Administration (HRSA) of HHS.

Noting that these three off-the-shelf lists did not specifically focus on women’s preventive health services, Senator Barbara Mikulski (D-MD) proposed what came to be known as the Women’s Health Amendment, which now appears as Section 2713(4).  Thus Section 2713 of the ACA lumps together preventive services using very different clinical evidence standards — strict for USPSTF and CDC, looser for pediatrics, and no requirement for any evidence at all for women’s preventive health services.

Adam Sonfield of The Guttmacher Institute, a leading reproductive health think tank, speculated to GMP that perhaps insurance companies voluntarily may extend no-cost reproductive health services to men.  He noted that Section 2713 of the ACA “establishes a floor, not a ceiling.”

Unfortunately, this disregards the last paragraph of Section 2713(a), which created what lawyers call a safe harbor, legally protecting insurers who deny coverage to men:

Nothing in this subsection shall be construed to prohibit a plan or issuer… to deny coverage for services that are not recommended….

At the same time, Section 1557 of the ACA broadly prohibits sex discrimination. As any first year law student can tell you, all provisions of a law must be read together. Section 1557 starts, however, with an exception clause (“Except as otherwise provided in this title,”).  This could allow the Obama administration to blame Senator Mikulski and the Democratic-controlled 111th Congress for mandating sex discrimination against men by limiting the benefit of Section 2713(4) to women.

On the other hand, the ACA is the signature achievement of President Obama, and HHS has taken full credit for making no-cost-sharing preventive reproductive health services available only to women.  Moreover, it was clearly the actions of the IOM committee and HHS, not Congress, which extended Section 2713 to reproductive health care in a manner discriminatory against men.  It may also be worth noting that the exception clause of Section 1557 would be of more legal use to an insurer refusing to extend no-cost reproductive health services to men, than it would be to HHS.  HHS itself may be open to a sex discrimination lawsuit for its actions.

Despite Mr. Sonfield’s sunny view of insurance company generosity, insurers would be justified in citing the HHS action as a reason not to extend no-cost reproductive health care to men. If a Federal agency has acted to discriminate against men’s access to reproductive health care on the basis of sex, why shouldn’t an insurer take full advantage of the Section 2713 statutory safe harbor to do the same?  Why should an insurer pay out any more than it has to, after all?

Senators Barbara Mikulski (D-MD) and Olympia Snowe (R-ME) sponsored key portions of Section 2713. The office of Senator Snowe had no comment for the GMP at press time, while Senator Mikulski responded to say that “additional protections for women” were “vitally important” because of women’s “unique medical needs” and “average” lower income levels. Dr. Linda Rosenstock, Dean of the UCLA School of Public Health, and Chair of the Institute of Medicine (IOM) committee that made the recommendations adopted wholesale by HHS, referred all questions to HHS.  Dr. Paula Johnson of Brigham and Women’s Hospital in Boston, and an IOM committee member, also declined comment to GMP.  HHS was repeatedly contacted by phone and by email, up to the Assistant Secretary for Public Affairs, Chris Stenrud.  HHS did not offer a justification for its decision to discriminate against men’s access to reproductive health care.

Mind the Gaps

In light of the decision by HHS not to explain why it acted to foreclose men from equal access to no-cost reproductive health services, the report of the Institute of Medicine (IOM) committee which produced the recommendations adopted wholesale by HHS, entitled “Clinical Preventive Services for Women:  Closing the Gaps” offers the key window into the underlying cultural assumptions.

The IOM report included this dissent by Anthony LoSasso, a health services economist with the University of Illinois at Chicago who is married to a prominent Ob/Gyn:

… the committee process for evaluation of the evidence lacked transparency and was largely subject to the preferences of the committee’s composition. Troublingly, the process tended to result in a mix of objective and subjective determinations filtered through a lens of advocacy.

GMP contacted Dr. LoSasso, who, unlike members of the IOM committee majority, spoke with GMP. The IOM majority responded to Dr. LoSasso’s dissent but, in contrast to the detail included in the dissent, the majority response is a single, conclusory paragraph.  It is available online through the link above.
Fairly read, the IOM panel majority report would appear to justify Dr. LoSasso’s dissent.  A repeatedly stated reason why any given preventive healthcare service was recommended for women without out of pocket cost is that women need the service in question.  However little if any effort was made to explain why men don’t need the same healthcare service when nothing about the service in question makes it useful only to women.  Even when the IOM majority ultimately decided not to recommend a service for women at this time (as in the case of type II diabetes, which as the IOM report admits, strikes men and women about the same) the IOM majority reasoned that women would benefit more than men because more life would be preserved for women than men. The IOM panel majority’s reasoning violates the ACA ban on discrimination on the basis of life expectancy, arguing that men’s shorter life expectancy means women get more benefit from treatment.  The IOM majority report also called for future identification of additional preventive health services, but only for women.

In fairness to the IOM committee, as quoted at the beginning of this article, the “independent” IOM was “directed” by HHS to focus purely on women.  That does not, however, explain the actions of the Obama administration.

Another major justification given in the IOM majority report was the overall average income gap between men and women.  The panel did not provide any citation for that claim. According to Dr. LoSasso, the gap was assumed to exist.

Yet a detailed analysis by Catherine Rampell in the Economix blog of The New York Times demonstrates that, even before adjusting for the greater number of hours worked outside the home by men, there is no significant pay gap between men and women earning below approximately $100,000 in annual income.   (The scattergraphs in her analysis are especially eye-opening; the post is worth a careful read.) And, as reported in Time Magazine, among men and women under 30, women now out-earn men in 147 of 150 metropolitan areas in the U.S., largely because younger women have substantially outpaced men in educational attainment. As reported there, young women average 8-percent higher incomes than young men.

In short, for the poor, the middle class, and the young—for whom co-pays and deductibles pose the greatest hurdles—men face the same or greater financial barriers to health care than women.  The IOM committee recommendation and the resulting HHS rule mandate that Kim Kardashian, Paris Hilton and Oprah Winfrey receive free reproductive health care, while a man employed as a garbage collector, gravedigger, or landscaper can be asked to shell out co-pays, co-insurance, and/or deductibles for the same care.

 

—Photo Leader Nancy Pelosi/Flickr

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About Greg Peterson

Greg Peterson is a married, middle-aged transactional lawyer. His greatest accomplishments are having taught one daughter to Eskimo-roll a kayak and another daughter to bake.

Comments

  1. The healthcare system of U.S.A seems….quite strange, why is it such a mess?

  2. Anthony Zarat says:

    So, here it is.

    But the real question, the deepest question, the unanswerable puzzle is this:

    Given that Obamacare is the single largest act of federal discrimination against American citizens since Jim Crow, how is it possible that the ONLY national dialogue about Obamacare falls under the absurd heading of a make believe “war on female contraception?”

    How can American media fail so completely, to address in any way, a bill that is so profoundly sexist and discriminatory against men and boys?

    How can BOTH political parties fail so completely to mention or criticize this deficiency, the most salient aspect of Obamacare?

    How can every talk show host, on the left and on the right, scream back and forth about “religion” and “female rights”, neither of whifch has ANYTHING to do with the true dark side of Obamacare?

    The real story here is, and allways has been, the SILENCE.

    The deafening silence of a nation so obsessed with misandry and sexism that direct, explicit, intentional harm can be done to men and boys, on a scale that is almost inconceivable, and receive no notice. No attention. No mention.

    This is the truest, and saddest, indication of how different the nation we really live in is, from the nation we think we live in.

    • Peter Houlihan says:

      “Given that Obamacare is the single largest act of federal discrimination against American citizens since Jim Crow,”

      As awful as this is, I really think the Jim Crow comparisons need to stop. It’s not really all that comparable and it’s just going to piss people off.

  3. First off, thanks Greg, this is an awesomely informative piece on something that I’ve been interested in and trying to tackle myself.

    What strikes me is that the ACA seems to be pleasing almost no one. I’m not sure if this is a good or bad thing. On one hand, it appears conservatives say it’s going too far, it’s socialized health care and not fit for capitalism. On the other hand, it appears to be unequal, and not going far enough to give the same coverage to both sexes. I recently had a piece talking about how Obama’s 2012 re-election campaign was advertising that the ACA would equalize women’s health care costs in many states where they pay up to twice as much as men. However, maybe this “equalization” has over-zealously flipped the tables?

  4. I don’t understand. How can women do this to us! They say there is a pay gap and that therefore men must pay higher premiums, be denied healthcare and pay for women’s healthcare. I don’t understand how they can do this to us!

    • Do what? Forget to care? I’m not sure…I live in Australia where we only pay more for car insurance, health seems pretty level afaik. But considering the absolute stink and way many conversations recently have talked about attacking women and their health I find it a bit troubling that none seemed to realize they still get the better deal compared to men with this (at least from what I hear here).

    • Anthony Zarat says:

      Women are not doing anything to you. Many women oppose Obamacare, and many Men support it.

      If you want, you can call Obamacare a feminist attack against men and boys. However, this also would not be completely true, because many feminists do not support discrimination against men and boys.

      Somehow, Obamacare happened. The important thing now is to repeal it or defeat it at the Supreme Court level. Either way, it has to go. If Obamacare stands, there will be no dawn for men and boys.

      • “many feminists do not support discrimination against men and boys.”

        Really? “Many?” When? This would be a perfect opportunity for “many feminists” to show that they don’t support discrmination against males. So, where is the opposition of “many feminist?” Where is their outrage? There is none. They are evidently content for males to suffer discrimination here.

        Question: when feminists feel that women are being discriminated against, when are they EVER silent? I have been waiting for this to explode like the Sandra Fluke thing did, with calls for Congressional hearings, and hearing about the “war on boys and men.” But, this? Nothing. Not a single word.

        I see no evidence that “many” or even “a few” feminists oppose discrmination against men and boys. If they did, they would oppose this. They aren’t.

  5. Eric M. says:

    Excellent expose.

    Yet more evidence of how gender inequality is promoted, embraced, and defended when males are on the short end.

  6. Peter Houlihan says:

    I’m amazed I missed this, I’ve been waiting for an article on this for ages (I’m really not qualified to write one).

  7. GREAT Article!! I hope someone from GMP can explain why this wasn’t on the front page. I got the link through another article responses. I’d like to add something about healthcare. There is a difference between healthcare itself and coverage that pays for the healthcare. The government mandates levels of benefits that insurance companies provide. No one seems to understand that some of the problems we have today is because of government intervention. Then there is cost shifting which means that the healthcare providers shift the cost of care to the private pay to recuperate their losses incurred by people who either paid for under government programs or simply not paid for at all. Cost shifting is where the fee for service patients experience an increase in their cost to compensate.

    Take a look at the current government subsidized health programs that are poorly managed … this is what we want more people to be covered under?

  8. John Anderson says:

    I was actually planning on voting for Obama prior to reading this. I supported Obamacare, but have changed my opinion of both. I supported the change in the FBI definition of rape because it was better, more accurate, and I didn’t perceive it to hurt men. An argument can be made that gendering rape will lead to legislation that could harm men in the long term, but the change in the definition itself does not harm men. Had the ACA stuck with health services that disproportionally benefitted women, but did not exclude men, I’d have no problem supporting it. This legislation will harm men as the cost of health insurance and healthcare will shift toward men.

    @ Anthony Zarat

    “If you want, you can call Obamacare a feminist attack against men and boys. However, this also would not be completely true, because many feminists do not support discrimination against men and boys.”

    I’m not sure I’d say many. I’m unaware of any feminist who opposes discrimination against men and boys in all situations. I convinced one feminist on GMP to support a ban on MGC, but even she would only support it within the U.S. If bodily autonomy is a right, then it should be universally applied. Otherwise it’s just license provided by the state.

    • There are loads of women/feminists who support a ban on circs/MGC/FGC altogether. Loads. Just saying.

      • John Anderson says:

        @ Julie Gillis
        I understand, but what Anthony said many feminists do not support discrimination against men and boys. I think the statement is untrue. I think many feminists oppose most instances of discrimination against men or boys. I might even say most, but I’m not ready to. A few feminists probably oppose all discrimination against men and boys and some recognize that the world is sometimes unfair, hold their noses and support discrimination against men as the fairest means to address an issue. I remember one feminist saying that it sucks that men don’t have abortion rights, but to do so would give them control over women’s bodies and deprive women of bodily autonomy, which is a worse situation.

        It was an old post so I couldn’t ask her position on male victims of rape or a “legal abortion”, which almost all feminists seem to oppose even though most also oppose requiring a father’s consent for an adoption or requiring women to pay child support to adoptive couples if the father’s consent is not acquired. I understand that feminists would argue that women give up their rights during an adoption. I understand, but not necessarily in an open adoption and requiring women who fail to get the father’s consent would to some effect protect fathers whom the women can identify, but won’t identify because they fear the father will block an adoption that they want. That’s why I believe the vast majority of feminists support some discrimination against men/boys in at least certain circumstances.

        Many feminists also qualify their support to ban MGC such as only in the US or as long as it has a religious exemption. They don’t seem to have the same beliefs when it comes to FGC. A person’s culture is no longer worthy of respect. A person’s religion is only valid if it conforms to one of the “established” religions. Even if it does if FGC is not required only highly desired, I’m struggling with the words, but it would be akin to the person asking Jesus, “What do I have to do to get into heaven?” and Jesus responding, “Follow my commandments.” As being required and Jesus saying, “Love thy neighbor!” as being highly desired because that wasn’t a requirement to attain heaven. Still, do I have to conform to an established religion to get a religious exemption? I have bodily autonomy, but not autonomy of the mind or spirit.

  9. Anthony Zarat says:

    Anti-male sexism in Obamacare may have an immediate solution.

    The betting odds on Intrade predict 63% chance of reversal on the individual mandate.

    If men can buy any kind of insurance that we want, it will not matter how one-sided and sexist the coverage of “qualified” insurance becomes. We will just buy insurance that covers the things that we need. Women will benefit from having qualified healthcare that covers their needs, and men will benefit from having the option to buy non-qualified healthcare that covers our needs.

    If the supreme court does the right thing, this issue may have a very happy ending.

  10. “The war on men and boys” indeed.
    The difference is that men are busy *being* whilst women are busy *complaining.*

    Too much will never be enough,someday that dam is going to break,and it will be spectacular.

  11. Wilhelmina de Jong says:

    The majority of law makers are male, so are the majority of senators and congressmen. You guys are doing that to yourself.

    • John Schtoll says:

      Tell me again, how it is a privilege to have the majority of those in power be MALE. Interesting isn’t it. Time and time again over the last 25 year we have seen men produce legislation that essentially ignores the needs of men, YET the is a ton of press over SOME men wants women to pay for their own BC, yes I agree there are men who want to restrict abortion etc, but this isn’t to the benefit of men (from what I can tell). This is why these so called “men privileges” don’t really stand up when you shine a light on them.

  12. I totally agree with you, these services should definitely be available for men as well (BTW I identify as a feminist, so all you commenters vilifying feminists, here is your black swan) and it is wrong that they will not be. One question though, purely because I don’t know, what contraception is available for men that could be covered by health care? Even women will only have birth control pills, nuva ring, IUDs, etc.(not condoms, spermicide, etc.) covered as contraception but these things do not work for men and there is no comparable hormonal (as in a prescription is needed) contraceptive for men at the moment.

  13. SomeDude says:

    This is a interesting and well researched article. Thanks for putting it together.

    I do have a problem with it though. It seems like this article is being buried. If I hadn’t noticed it last night when it was briefly in the “Most Recently Posted” section I suspect I would have never noticed it.

    It is a new article that doesn’t get to be one of the pictured article on the top of the site. That might be an editorial decision on what is put there I guess.

    I can’t find linked any place on the front page.

    Why doesn’t this article show up under the “Most Recently Posted” section? It came out last night. I might be mistaken but I also thought it came out after the Kurt Cobain article that is still listed in that section.

  14. “I do have a problem with it though. It seems like this article is being buried. If I hadn’t noticed it last night when it was briefly in the “Most Recently Posted” section I suspect I would have never noticed it.
    It is a new article that doesn’t get to be one of the pictured article on the top of the site. That might be an editorial decision on what is put there I guess.”

    To Somedude: To be honest I’ve heard this site gets its funding from feminist groups. I’m surprised it was allowed to be posted at all.

  15. Navigating this site is weird sometimes. Some articles stay on the front page for months, some vanish in a day or two.

  16. Eric M. says:

    Very, very good question.

  17. Valter Viglietti says:

    “I’ve heard this site gets its funding from feminist groups”

    I’d be very surprised if it was true. Do you have any source to link, or is it just rumours and voices?
    GMP Editors, any reply?

    And, yes, this piece (relative) invisibility is puzzling – and a shame.

  18. Hey Ryan, you realize what the definition of feminism is right? It’s: things have been pretty shitty those last few thousand years, now let’s work together to get rid of these oppressive gender roles, expectations and inequalities! I really think this site’s manifesto jives completely with that and see no problem with it receiving support from a like-minded organization.

  19. That is a rumor, and is untrue. I’ll let Lisa Hickey weigh in.

  20. Anthony Zarat says:

    It was founded with the support of Ms. Magazine:

    “Back in June when the Good Men Project Magazine had just launched, Ms. magazine took us under their generous wing, calling the mag “what enlightened masculinity might look like in the 21st century.”

    http://goodmenproject.com/press/ms-magazine-talks-shop-with-lisa-hickey/

    This is not necessarily a bad thing, particularly since Ms. Magazine is what I would call moderate-feminism.

  21. Eric M. says:

    Better yet, why not allow this article to appear?

  22. Anthony Zarat says:

    :) Yep

  23. Peter Houlihan says:

    I think he was referring to the fact that it didn’t show up on the front page feed like most other articles.

  24. Lisa Hickey says:

    Hey all — that article was poorly worded. I am actually going to change it now because it is confusing.

    It simply meant that Ms. Magazine wrote about us early on. That’s it. Just like The Atlantic, The New York Observer, The Boston Globe, and dozens of other mainstream media companies also wrote about us.

    We are not funded by any organization. We partner with hundreds of them.

  25. That’s been fixed.

  26. The Bad Man says:

    “We are not funded by any organization. We partner with hundreds of them.”

    *Somebody* provided you with half million of start up capital. Are you going to be honest and reveal the source?

  27. One of the takeaways of this article is that if feminist groups were truly like-minded in pursuing equality, they would have fought against this discriminatory ACA legislation with the same determination with which they supported Sandra Fluke and other causes where they believe women are discriminated against.

    Instead, once again, they fought for inequality when it proved to be to their advantage.

  28. Anthony Zarat says:

    Not quite Eric. Sandra Fluke was complaining about ONE thing that, in any case, men are also denied. Men are also denied a list of other advantages that women are not denied. And, of course, the structural discrimination that is builtinto ACA means that every year, there will be more and more anit male discrimination in ACA.

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