​Make Room for Male Methods: Why We Should Expand the ACA Contraceptive Policy to Include Men

"Consider This"

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Author:

Lisa Campo-Engelstein, Ph.D.

Alden March Bioethics Institute, Department of Obstetrics and Gynecology, Albany Medical College

Consider This:

In June, Vermont passed a law requiring insurance companies to cover vasectomies without cost-sharing [1]. The purpose of this law is to rectify an oversight in the Affordable Care Act’s (ACA) contraceptive coverage: that it only applies to women. Since the ACA lists contraceptive coverage under preventive services for women and not preventive services for all adults, men are excluded [2]. By focusing only on women, the ACA inadvertently condones and upholds a problematic contraceptive arrangement in which women shoulder the vast majority of the responsibility for contraception. The Vermont law is an important step in recognizing that men do and should play a role in reproductive matters.

While shared contraceptive responsibility is not fully achievable today for heterosexual couples who want nonpermanent methods, as there are no long-acting, reversible contraceptives (LARCs) for men, sterilization is an area where men and women can share contraceptive responsibility. However, women are over 3 times as likely to choose sterilization (25.1%) than men (8.2%) [3] despite the fact that vasectomy is faster, safer, less invasive, and more effective [4]. Moreover, tubal ligation is four times more expensive than vasectomy (average cost of $2,912 for tubal ligation versus $708 for vasectomy) [4]. Tubal ligation is so much more prevalent than vasectomy, at least in part, because of gender norms. Reproduction is generally associated with women and since the introduction of the pill, there is a social expectation that women assume responsibility for contraception, including sterilization [5].

Differences in insurance coverage for sterilization, namely the fact that tubal ligation is fully covered without any cost-sharing, could lead couples to choose tubal ligation purely for financial reasons. To my knowledge, there is no data on whether the ACA’s contraceptive policy affects heterosexual couples’ decision regarding which partner will undergo sterilization.

In order to get a better sense of what the cost difference might be for a couple choosing vasectomy over tubal ligation and Albany, New York, I decided to examine local insurance plans. I searched the New York State Marketplace (https://nystateofhealth.ny.gov) for insurance plans for couples to gain easier access to information for both men and women. I chose mid-level “silver” tier plans with the highest premiums per company for a total of 37 plans. There was no information about sterilization coverage on the marketplace website or on the websites for the insurance companies. I randomly selected 9 plans to call (~25% of the total plans) to determine their sterilization coverage. Of the 6 insurance companies who were able to answer my questions, all cover tubal ligation with no cost-sharing and all cover vasectomy with cost-sharing.

These results are surprising, and encouraging, because other studies have found that a quarter of insurance companies do not cover vasectomy at all [4]. Yet the fact that all nine insurance companies in my sample require cost-sharing for vasectomy but not for tubal ligation is troubling. Even if a man has insurance that covers vasectomy, he will still probably end up paying a couple hundred dollars out-of-pocket for the procedure depending on his cost-sharing rate [4]. Payment for sterilization is typically an upfront lump-sum and this cost may put vasectomy out of reach for some couples. Couples with lower socioeconomic status are less likely to rely on vasectomy than those with higher socioeconomic status [3] and while there are many reasons for this, one reason may be that the out-of-pocket cost for vasectomy is higher than for tubal ligation. Even for couples with greater financial means, it seems reasonable that they would factor price into their decisions about which partner undergo sterilization and the lack of any cost-sharing for tubal ligation may be the tipping factor in some couples’ decision. In short, that tubal ligation is covered with no cost-sharing by all insurance companies in my sample may incentivize couples to choose it over vasectomy.

The ACA’s lack of coverage for vasectomy reinforces our cultural contraceptive arrangement that largely holds women responsible for contraception while absolving men from similar levels of responsibility, especially in monogamous relationships where couples are more likely to choose sterilization or LARCs. The ACA’s contraceptive policy not only excludes vasectomy, but it also excludes all current methods (unfortunately the only other method available to men is male condoms) and future male contraceptives (some of which are currently under development) [2][5]. Male condoms are not exclusively a male method, as 15.3% of women state they use male condoms [3]. In some cases, women provide and negotiate male condom use, making it somewhat of a shared method rather than a method that is used independently by men without any involvement of women. Furthermore, 8.2% of women rely on their partner’s vasectomy as their main contraceptive method, resulting in close to a quarter of all women who depend on male methods [3]. While the ACA policy had the good intentions of providing no cost-sharing for contraception for women, it failed to account for women who rely on male methods. Moreover, the ACA policy neglects men’s role in contraception and diminishes their reproductive autonomy by conflating reproduction and women.

In sum, this policy is bad for women – it burdens them with the full responsibility of contraception; it is bad for men – it overlooks their reproductive responsibility and autonomy; and it is bad for society – in order to further the public health goals of reducing unintended pregnancy, we need to include all parties and all effective contraceptive methods. There are a handful of ways to resolve this issue [4], including passing a state law like Vermont did, as well as federal approaches. However, given the new leadership in Congress and in the White House’s insistence on overturning the ACA, a federal approach seems unlikely at this point. In fact, the entire ACA, as well as its contraceptive policy may be in jeopardy, which would be harmful for both women and men’s reproductive responsibility and autonomy. Regardless of the healthcare system in place – be it the ACA or something else – it is imperative that both female and male methods be covered for the reasons I have outlined here.

Acknowledgments

The author has no conflicts of interest to declare and received no funding for this research.

References

1. Sananes, R., Vermont Insurers Must Now Cover Vasectomies, in National Public Radio. 2016. p. http://www.npr.org/sections/health-shots/2016/06/18/480133743/vermont-insurers-must-now-cover-vasectomies.

2. Services, U.S.D.o.H.H. Preventive Services Covered Under the Affordable Care Act. 2010 September 27, 2012; Available from: http://www.hhs.gov/healthcare/facts/factsheets/2010/07/preventive-services-list.html.

3. Daniels, K., et al., Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15–44: United States, 2011–2013 N.C.f.H. Statistics, Editor. 2015, National Health Statistics Reports.

4. Nguyen, B.T., G. Shih, and D.K. Turok, Putting the man in contraceptive mandate. Contraception, 2014. 89(1): p. 3-5.

5. Campo-Engelstein, L., No more larking around! Why we need male LARCs. Hastings Cent Rep, 2011. 41(5): p. 22-6.

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3 Comments

Go to the profile of Derek Wilson
Derek Wilson over 1 year ago

The author makes excellent points and I wholeheartedly support the view that male methods should be covered equally. would like to add a couple further points.

1. The insurance 'coverage' for vasectomies (with cost share) is essentially meaningless in the ACA age; most policies are high deductible, meaning the patient bears the full cost of the procedure.

2. My state - Washington State - has a contraceptive equity law, and an equal rights amendment that probably supports a broad interpretation of the equity law to cover males and sterilization. A male resident of Washington State could make a case to the insurance commissioner or the court, that insurance issued in Washington is legally required to cover male and female sterilization equally. Other states may have similar laws.

3. For me personally , the cost of a vasectomy was prohibitive and I did not get one; my partner stayed on the hormones. The average $708 mentioned in the article is much lower than what I ever found. I suspect it is not a realistic number, and it may still lie outside of affordability for many.

Go to the profile of Lisa Campo-Engelstein
Lisa Campo-Engelstein over 1 year ago

Derek, thank you for your comments. You bring up some important points. The average cost of vasectomy is surely more than $708 in some places and even at $708, it is still cost prohibitive for many people. Furthermore, as you rightly point out, individuals with high deductible policies may not be able to afford such a high cost procedure, especially all at once. You are lucky to live in a state with a contraceptive equity law and I hope more states enact similar laws soon.

Go to the profile of Mary Samplaski
Mary Samplaski about 1 year ago

As a Urologist, I see too many men who want to have a vasectomy but do not because of out of pocket costs. This is a shame for all of the reasons listed above. This is an issue that health care providers need to come together on, to lobby for equal coverage. Change is slow and will not happen unless if we encourage it.