Jennifer from Wing of Zock hosted the Health Wonk Review today, and it’s an excellent edition. One of the most interesting entries is from Hank Stern of InsureBlog, writing about the lack of covered men’s preventive services on new ACA-compliant plans.
Overall, I agree with Hank on this one. In the pre-ACA days, women by far got the short end of the stick when it came to health insurance. I am very much in favor of the reforms that have banned gender rating, added maternity benefits to all policies, and made so many women’s preventive services available with no cost-sharing. Any cost sharing at all, even a small amount, significantly reduces the utilization of preventive services… a lot of people – men and women – have a hard time spending money to go to the doctor when they’re not sick. And HHS has some very valid explanations for why they have focused so heavily on preventive care for women – it’s worth a read.
If the goal is to get people to utilize preventive care, doing away with cost-sharing and covering all recommended preventive care is the obvious way to go. But Hank’s point about men is certainly valid. The Washington Post reported on this a couple years ago, and not much has changed since then. It appears that a big part of the problem is that medical experts simply haven’t developed conclusive guidelines using comparative effectiveness research when it comes to recommendations for men’s preventive care. Some of the ACA’s preventive care mandates do apply to men: one screening for abdominal aortic aneurysm for 
older men who have ever smoked is an example. And some preventive care benefits apply to men and women: alcohol abuse screening, blood pressure screening, colonoscopies, HIV testing, and vaccines are all examples.
But while women are able to obtain a basic annual exam at no charge, men don’t get the same benefit. Several of the screening tests that are conducted during the annual exam are covered with no cost-sharing for men, but there’s no provision to cover the actual wellness visit itself for men enrolled in private health insurance. And Hank’s point about PSA exams is correct: coverage for them is not mandatory under the ACA. This is because the US Preventive Services Task Force does not recommend them… it actually recommends against them, and only services that are recommended by the USPSTF are included in the preventive care mandates. This brings us back to the problem of a dearth of comparative effectiveness research and recommended screening for male-specific preventive care.
One particular area of concern for me is in regard to contraceptives. I am very much in support of the contraceptive coverage mandate. I know a lot of opponents of the mandate believe that birth control is cheap and that it’s something people should fund themselves. But note that long-term birth control – the most effective kind – is certainly not cheap in terms of up-front costs. What is our end goal here? I believe it should be to get to a point where almost all pregnancies are intentional. In the US, we’re far, far from that mark. About half of US pregnancies are unintended, which has all sorts of negative ramifications for women and infant health. Our rate of unintended pregnancies is the highest in the developed world – certainly not a category that any country wants to lead.
We know what is scientifically proven to reduce unintended pregnancies: contraception. Particularly long-term contraception. Colorado recently made headlines by reducing the teen birth rate by 40% over four years. The state accomplished this by providing free or low-cost long-term birth control to young women. This is far more effective than drug store solutions (condoms) or even prescriptions for daily pills, which have a particularly high failure rate among teens because of compliance issues. The program was funded by a donor, but now that the ACA is in place, all women with health insurance have access to the sort of highly-effective, long-term (that part is key) birth control that leaves no room for user error. IUDs provide excellent birth control. But they come with a high up-front cost ($500 – $1000 in most cases), which is prohibitive for many women. Averaged out over five years, the cost of an IUD is on the low end of what oral contraceptives cost. But if women have to pay the full cost at the beginning, many are unable to afford it. When cost is not an issue, women overwhelmingly choose long-term birth control as their contraceptive of choice.
And thanks to the ACA, women who are sure that they don’t want children in the future also have access to tubal ligation – a highly effective procedure that carries a price tag between $1,500 and $6,000.
But I feel strongly that vasectomies should have been included in the contraceptive mandate as well. It’s true that women bear the brunt of the burden of pregnancy and pregnancy prevention in many cases. Condoms and vasectomy are the only reliable male options. But vasectomies are much less expensive ($350 to $1000) and less invasive than tubal ligation. If a couple decides that they don’t want any future children, wouldn’t it make sense for them to have the option for either partner to have access to a sterilization procedure? The way our system currently works, the insured couple will be biased in favor of selecting tubal ligation, simply because it’s available to them with no cost-sharing. It’s not “free”, because they pay for it with their premiums… but they have to pay those either way, so from their perspective, it can be seen as “free”. But if a vasectomy were also available with no cost-sharing, the couple might be inclined to choose that option instead, which would ultimately cost less for insurers – and thus insureds. To me, this one seems obvious. Instead of mandating all FDA-approved contraceptives for women, they should have simply mandated all FDA-approved contraceptives, period.
I have no doubt that as the USPSTF changes its recommendations over the years, so too will the mandated preventive care benefits change. Some things will no longer be recommended, and others will be newly recommended and covered. Hopefully there will be more focus on men’s preventive health as we go forward.
