The Affordable Care Act requires everyone to carry insurance. So why doesn’t it give men and women the same coverage? Part two of a series on the ACA.
The decision not to guarantee poor, middle-class and young men the same access as women to birth control and reproductive health services is especially shocking because President Obama’s healthcare plan already went out of its way to level the health care playing field between men and women in two other, fundamental ways.
As is common knowledge by now, the ACA requires all individuals to carry health insurance or to pay fines that will be collected through the IRS. Dr. LoSasso noted to GMP that young men have been the least likely to carry health insurance, instead gambling on their invincibility. The ACA individual mandate requires young men to bear the common burden of health insurance costs. Under the ACA young men will no longer be so-called “free riders.”
Second, and just as important, the ACA bans gender-based insurance premium pricing. Insurance companies charge women more than men for the very same individual health insurance policies, and group policies for groups with more women than men also tend to cost both employer and employees more, in the majority of states.
As Adam Sonfield explained to GMP, the primary reason insurance companies currently charge men less is that men, especially young men, just don’t go to the doctor nearly as quickly or as often as do women.
In effect, the sex-neutral insurance pricing required by the ACA already shifts some of the cost of future medical services consumed by women to men. The 2012 report cited above estimated the additional premium costs now borne by women to be over $1 billion a year. Thus, under the ACA, men can expect to bear at least half of those costs—half a billion dollars a year—for services consumed by women.
The theory behind these two fundamental health insurance payment changes wrought by the ACA, is that we are all in it together when it comes to healthcare. Until, in the case of men’s access to reproductive health services and preventive care for men’s diseases, we aren’t.
Limiting Men’s Ability To Control Their Own Fertility
When it comes to contraception and reproductive health, health care providers already woefully underserve men. The Guttmacher Institute concluded that there are “substantial missed opportunities to educate and counsel adolescent men in health settings. Although two of three males aged 15-19 had a physical exam in the past year, fewer than 20 percent received counseling or advice from a health care provider about birth control or STIs, including HIV.”
Adam Sonfield pointed out to GMP that few family-planning clinics offer programs focused on, or friendly to, men. Mr. Sonfield referred GMP to the most recent government data: males were a mere 8% of U.S. family planning clinic patients in 2010. This at least increased from a scant 3% in 1999. The same Guttmacher Institute report cited in the previous paragraph lists more depressing statistics: Only four percent of clinics offer special hours for males. More than a quarter of young men have never received information about birth control from either school or their parents, and the levels are even higher among African-American and Hispanic men. Imposing extra costs on men seeking contraceptive and STI prevention counseling, and creating insurance disincentives for doctors to reach out to men, will not help.
Erin Gloria Ryan put it well in her recent Jezebel post: “When a woman consents to sex, she is not also consenting to pregnancy.” A woman in the U.S. has a constitutional right to terminate hosting a fetus and unilaterally end any obligation to support and raise a child. A precisely opposite legal regime applies to men. When a man has heterosexual sex he is presumed to have consented to paternity and a couple of decades of child support. To control their own fertility, straight men, unlike women, are entirely dependent on complete abstinence or the highly competent use of very limited and often ineffective birth control methods.
In a February 25, 2012 letter to the editor of The New York Times, Cory L. Richards, the executive vice president of The Guttmatcher Institute, stated:
While it may not be so to a method like the condom, cost has been shown to be a significant barrier to the most effective methods available because these methods can cost hundreds of dollars up front. When a California health insurer eliminated cost-sharing for long-acting intrauterine devices, implants and injectibles, enrollees’ use of these methods increased substantially, and their risk of contraceptive failure plummeted.
Yet the total cost of an IUD or implant is equivalent to (and in some cases less than) the cost of vasectomy. Further, reversible female procedures such as IUDs or implants, and permanent sterilization from tubal ligation or vasectomy (all with failure rates <1 percent) are all vastly more effective than condoms (with a 17 percent failure rate in normal use). Cost and effectiveness are simply not rational reasons to subject men to cost-sharing for vasectomies, while covering IUDs or implants without cost-sharing by women. Mr. Sonfield assured GMP that despite Ms. Richard’s letter to The New York Times, “Guttmacher fully supports no-cost-sharing coverage of vasectomies.”
Worse, the HHS decision to allow insurers to bar men from no-cost-sharing birth control is likely to deny U.S. men truly effective, reversible birth control methods for years to come. We know from decades of research that effective, reversible hormonal and non-hormonal male birth control is achievable. But it will be costly to bring male birth control pills, implants, and procedures through FDA trials to market. Why would Big Pharma invest in the effort after HHS has decided that men can be subject to often sizeable co-pays, co-insurance and deductibles for hormonal birth control? Aren’t those cost barriers more likely to depress demand, making it less likely products will be brought to market? U.S. trials for effective, reversible non-hormonal procedures like RISUG—renamed Vasalgel in the U.S.—which don’t result in pharmaceutical royalties have yet to receive funding from the sources one would normally think interested. Will venture capitalists, non-profits, or foundations invest the needed $4 to $5 million in developing and marketing effective, reversible, non-hormonal birth control to men, if the resulting products do not have a level cost playing field with birth control methods for women?
Ultimately, the Federal decision to disregard men’s need for equal access to birth control has tragic consequences not just for men, but for women and children too:
The father’s intention status appears to have significant effects on his involvement during pregnancy and following the birth. This, in turn, is associated both with the mother’s receipt of prenatal care and her likelihood of reducing smoking during pregnancy. In addition, infants born to mothers and fathers who differed in their pregnancy intention face significantly higher risks of several adverse maternal behaviors and birth outcomes than those born to parents both intending the birth.
Men understand this, apparently better than the federal government, and consistently report strong desire for effective, reversible male birth control. With just two practical, but flawed methods available to men—condoms and vasectomy—men still account for a third of total contraceptive use in the U.S. In the Netherlands, which has national health insurance that covers vasectomies, half of couples 35 and older use sterilization, 70 percent of which are vasectomies. A massive study involving more than 9000 men aged 18-50 in nine countries, including 1500 men in the U.S. alone, found that between 50% and 83% of the men currently used contraceptive methods and over 55% of men (reaching as high as 71% in some countries) wanted male hormonal birth control. The notion that men don’t want or won’t use effective, reversible, long-term contraception is ludicrous and offensive.
Saddling men alone with extra cost burdens for reproductive health services not only denies men equal opportunity to control their own fertility and be free of STIs, but also artificially discourages men from joint responsibility for reproduction. It runs counter to responsible fatherhood efforts. It is profoundly sexist.
A Failure of Consciousness, a Failure of Leadership
The Federal decision to mandate no-cost preventive reproductive healthcare only for women must be viewed against the backdrop of 1) the sex discrimination prohibition in the ACA; 2) gender-neutral insurance pricing and the individual mandate under the ACA; 3) widespread lack of reproductive health and suicide prevention services for men; 4) the five-year life expectancy gap that disfavors U.S. men; and 5) the 50-year drought of public or private research funding for truly effective, reversible birth control for men. Any given man is some woman’s son or grandson, just as any given woman is some man’s daughter or granddaughter. Are we in this together, or aren’t we?
It is fantastic that women have reproductive rights and many contraceptive choices. No-cost preventive care addressing women’s unique health concerns is necessary. That is not the issue. The issue is that this administration and leading health organizations that purport to believe in widespread access to health care do not seem to hold men in equal regard to women when it comes to birth control, STI services, HIV counseling and screening and counseling for intimate partner violence.
When contacted by GMP, for example, Planned Parenthood was unable to cite anything it had done—or would do—with its impressive lobbying and public affairs operation to encourage HHS to provide men with equal access to reproductive health care under the ACA.
“Many in the field believe reproductive health is synonymous with women’s health,” Adam Sonfield told GMP. He explained men’s health advocates are far less organized than advocates for children or women. Men’s tendency not to see doctors as quickly or as often as women may reduce the medical community’s consciousness of men’s needs.
The Guttmacher Institute’s last major review of men’s reproductive health needs and barriers to meeting those needs found the following barriers to addressing the reproductive health of men in their own right: Absence of political will to turn advocacy into action; Lack of funding; Logistical challenges of incorporating men’s services into existing programs; and Inadequate staff.
Men are carefully trained from infancy not to show pain, not to complain about hard knocks and not to seek help. Men are also inaccurately assumed to be omniscient about matters of sex and sexual health. Under these circumstances shouldn’t it be the duty of HHS officials, Members of Congress, public health school deans, medical school professors, public health advocates, the philanthropists and boards who direct major foundations, and maybe even a U.S. President, to demonstrate leadership on this issue?
The IOM committee again provides a telling example of how far men’s health needs are from the awareness of even serious, intelligent, medical and public policy professionals. The committee discussed the ways in which heart disease in women presents and is managed differently from heart disease in men. At length, Dr. LoSasso said, “If we could bottle women’s heart disease and give it to men, it would be an improvement.” The other members of the IOM panel stared in incredulous silence.