The Affordable Care Act (ACA) survived another round at the highest court in the land last week.
It was one of the many battles that have been fought over it., but the resounding 6-3 decision in support of the ACA may make it one of the last, at least for a while.
But while Obamacare proponents celebrate the Supreme Court ruling, few pause to consider the glaring health-care sector that remains uncovered: male contraceptive methods.
Anyone who has followed the national debates over the Affordable Care Act since Obama announced his desire for the overhaul in 2009 know that contraception coverage has been one of the most controversial aspects of it.
The legislative discussions often spun out into larger debates about women’s rights and societal biases surrounding female sexuality.
Not for nothing did Sandra Fluke become a household name.
After she testified before members of Congress on contraception in 2012, national radio host (and jackass) Rush Limbaugh called her a “slut” and a “prostitute.”
Plenty of ink was spilled and attention rightfully paid to contraception coverage.
Under the ACA’s contraceptive coverage guarantee and specific federal guidelines issued this past May, there are 18 specific and distinct contraceptive methods that plans must cover without out-of-pocket costs.
All 18 are ones used by women. Notably absent are vasectomies and male condoms.
Adam Sonfield, a senior public policy associate at the Guttmacher Institute, has been analyzing the disparity between male and female contraception coverage under the Affordable Care Act and its effect on the nation’s public health.
His report in the Spring 2015 issue of the Guttmacher Policy Review highlights that 23 percent of female contraceptive users rely on methods used by their male partners, vasectomies and male condoms.
These are not covered with the no out-of-pocket cost guarantee that several female forms of contraception are.
Sonfield doesn’t find the sex difference in coverage particularly shocking, nor is he especially critical of policymakers’ failure to initially account for male contraception.
“Realizing there were some obvious gaps with women’s health, they [policymakers] filled that gap by establishing more recommendations related specifically to women’s health. That’s not a surprise [because] there have been real problems in the past with maternity care and contraceptive care not being covered accurately,” he tells The Daily Beast.
“In contrast, you don't think of too many gaps when it comes to men’s health. It tends to be the default for insurance plans to cover what men need,” he says, adding that it is even the “default for medical researchers to focus on men’s health.”
But that doesn’t mean there aren’t strong incentives for men and women to have this disparity in coverage remedied.
Sonfield’s larger and often overlooked argument is that not covering male contraception hurts women and men.
“Sometimes, it’s hard for people to understand [that] health care provided for one person has just as much if not more benefits for someone else,” he says.
“That’s certainly the case for contraception,” he says, but also points out that the same theory holds with preventive health. “Those services clearly have benefits beyond just the person who is treated.” The same holds with health coverage for sexually transmitted infections, as well.
The way the ACA’s contraceptive coverage guarantee is currently interpreted means there are incentives for couples to select female forms of contraception over male forms. Sonfield readily acknowledges that there are many cases in which a woman would want that control and may even prefer to keep her contraception secret from her partner.
At the same time, the status quo also creates incentives that do not necessarily make sense for couples or insurance providers.
For example, Sonfield notes in his report that “as currently interpreted, the ACA’s contraceptive coverage creates a financial incentive for couples to choose female over male sterilization, by eliminating cost-sharing for the former but not the latter.”
Tubal ligation is effectively promoted over vasectomies, even though the former is “more invasive than vasectomy and has a higher (although still very low) health risk,” he notes in his report. That makes “the incentive [toward female sterilization] a disservice to women.”
Moreover, a vasectomy is “considerably more cost effective than female sterilization,” so it is a disservice to health plan providers, as well.
Another marked disparity comes with condoms.
Currently under the interpretation of the ACA contraceptive coverage guarantee, female condoms are completely covered if a person has a prescription.
Sonfield notes that it is problematic that “even if a method is available over the counter, you still need a prescription if you want it covered.” But, at least with female condoms, unlike the more ubiquitous male ones, coverage is an option.
This disparity in coverage for female versus male forms of contraception has potentially grave implications, namely promoting an undue burden on women to handle the logistics of family planning.
“Excluding methods used by men from the contraceptive coverage guarantee sends a message reinforcing the all-too-common cultural attitude that contraception is solely a woman's responsibility,” Sonfield writes in his analysis.
Since the pill became available for contraceptive use in the U.S. in 1960 and granted women an unprecedented level of sexual freedom, it has simultaneously put the onus of family planning on their shoulders.
“There is certainly a widespread attitude that contraception is women's business, not men's,” says Sonfield. “That's an unfortunate attitude that people have been working to change for many years.”
Inadvertently, the ACA is perpetuating that burden. At the same time, it potentially has the power to reverse that trend through improving the coverage of male contraception.
Congress is one avenue for expanding the contraceptive coverage guarantee interpretation to include male forms, though Sonfield believes it is unlikely that this current Republican-dominated one would make that move.
Sonfield notes in his report that the Obama administration could also effect the change by adopting a “different interpretation of the ACA provision and define methods used by men as preventative care for women.” However, he writes that this is not a move the White House “would do lightly.”
A more promising potential source of change is the U.S. Preventative Services Task Force (USPSTF), an agency of health experts supported by the Department of Health and Human Services.
“Under the ACA, any positive recommendation from that body is automatically incorporated into the preventive services requirement after a one-year grace period,” Sonfield explains in his report. Thus, the USPSTF has the potential to issue a recommendation regarding the coverage of male contraception forms that could rectify the disparity.
While Sonfield declines to predict the odds that these changes will occur, he says he is only more hopeful in light of the recent Supreme Court decision.
“I think there is certainly more momentum now. There have been a lot of people arguing for a long time that it [ACA] is going to be going away and that has been an impediment to improving it,” Sonfield. “I think the president himself said, now we can move forward and make health care better.”