Pregnancy prevention: What about vasectomy?

While researching an upcoming story on preventive services,  I came across something perplexing:  Tubal sterilization for women is fully covered by insurance,  per the Affordable Care Act mandate,  while vasectomy for men is not.

The act mandates that specific preventive services be exempt from deductibles and other cost-sharing,  not only for policies bought through the ACA exchange but for employer-provided and other privately purchased health insurance  (grandfathered policies are the exception). The goal is making sure that money doesn't deter anyone from getting care that's likely to head off more serious medical issues and bigger bills.

The medical,  financial and societal benefits of preventing unwanted pregnancies seem clear.  So why not support men who are willing to step up?

Sonfield

"You hear that from everyone who looks at this. It doesn't make sense," says Adam Sonfield of the Guttmacher Institute, which focuses on reproductive issues and pushed for vasectomies to be included.

Early versions of the ACA incorporated preventive standards that were already in place from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention. Eventually it grew to include children's services recommended by the American Academy for Pediatrics.

And the Department of Health and Human Services commissioned the Institute of Medicine to create a separate list of covered preventive services for women. That list includes FDA-approved contraceptive devices and sterilization techniques.  But there's no parallel provision for men.

"This position seems particularly short sighted, and insurers should consider covering these services without cost-sharing anyway,"  Sonfield,  a senior public policy associate with Guttmacher,  wrote in 2012.  "Vasectomy is less expensive and less invasive than female sterilization, so it benefits no one to provide economic incentives for couples to choose female sterilization.  Moreover, contraceptive methods used by men and by women offer the same benefits for women’s health,  stemming from the prevention of unplanned pregnancies and the ability to time and space planned ones."

With a growing number of insurance policies requiring consumers to pay bigger sums out of pocket,  the bill for a vasectomy could be significant.  Planned Parenthood lists the cost as $350 to $1,000.  A Southern California public radio station recently did a price check and found fees ranging from $500 to $1,750.

Sonfield said he thought insurance companies would choose to exempt vasectomies from cost-sharing to encourage a cheaper,  safer alternative to tubal sterilization,  but he hasn't seen that happen. Other avenues for change would be for HHS to add vasectomies to the list of covered women's services or for the USPS Task Force to add it to the overall adult list. 

Congressmen want to revive end-of-life support

Thirty-four Democratic members of Congress,  including North Carolina's David Price,  recently wrote to the nation's top Medicare administrator urging her to adopt a plan that would reimburse doctors for time spent counseling patients about end-of-life care.

The letter to Marilyn Tavenner, administrator of the Centers for Medicare & Medicaid Services, notes that working with a doctor to create an advance directive ensures that the elderly will receive the type of care they want and reduces stress and depression among loved ones.

"We find it troubling that Medicare reimburses almost every medical procedure, yet places no value on the time doctors take to provide thoughtful counsel to prepare patients and families for the delicate,  complex and emotionally demanding decisions surrounding the end of life,"  says the letter,  composed by Rep. Earl Blumenauer of Oregon.

2009 Obamacare protest (Talking Points Memo)

Such reimbursements were part of an early version of the Affordable Care Act,  leading Sarah Palin to launch the stubbornly persistent idea that the president wants to create  "death panels" that would rule on whether the elderly are granted medical care.  I've always found that one of the more baffling twists to Obamacare politics; I don't know anyone who doesn't want some control over their final days.

The reimbursements were cut from the act that won approval,  but Blumenauer,  Price and others keep pushing to revive them.   The  "Personalize Your Care Act"  introduced by Blumenauer to provide Medicare and Medicaid reimbursement for voluntary end-of-life planning got 59 co-sponsors.  Among them are eight Republicans  (none from the Carolinas).  Price,  whose District 4 includes Raleigh, Durham, Chapel Hill and Fayetteville,  is among the sponsors,  as was Congressman Mel Watt of Charlotte,  a Democrat who later resigned to become director of the Federal Housing Finance Agency.  That bill was referred to the Ways and Means Subcommittee on Health,  joining the list of issues Congress hasn't acted on.

Last week's letter didn't include any Republican signers,  and Tavenner's office has not yet responded to a query about whether the letter will prompt any action.

Price

Price said he thinks it's important to keep pushing.

“The American Medical Association, the Institute of Medicine, and a bipartisan group of lawmakers support Medicare coverage of voluntary end-of-life counseling, which is already covered by many private insurers and Medicare Advantage plans," he said Tuesday.  "I strongly agree with Congressman Blumenauer that Medicare should empower seniors to develop and adopt advance directives to protect their dignity in the final stages of life."