Some find open conversations about sexual and reproductive health uncomfortable, yet many federal and state politicians comfortably and publicly debate which sexual and reproductive health services should be covered by payers. While economic considerations explain some coverage decisions, religious beliefs or moral convictions and the ensuing politics drive many coverage decisions.
Maternity care services
Coverage of maternity services has been comprehensive for decades. But that wasn’t always the case. The Pregnancy Discrimination Act (PDA), enacted in 1978, prohibited discrimination in the provision of employer-sponsored health benefits based on pregnancy, childbirth, and related medical conditions. In 1983, the U.S. Supreme Court ruled that the PDA also applied to dependents of insureds under employer-sponsored plans. Yet in 2013, before the ACA’s essential health benefits requirement took effect, 75% of nongroup plans did not cover delivery and inpatient care for maternity care. Why? Because excluding these services reduced costs and premiums.
Thankfully, the ACA made maternity care one of the 10 essential health benefits. For those familiar only with the new normal, this protection may seem unnecessary. But some conservative lawmakers have since suggested that maternity care coverage should not be a requirement. Access to maternity care services is apparently not viewed by all as a right.
Preventive services
Prior to the ACA, preventive women’s health services were not universally covered. Many payers were either unaware or didn’t care about the return on investment in preventive services. We’ve come a long way.
As per the ACA, nongrandfathered plans are now required to cover the services identified by the HRSA-supported Women’s Preventive Services Initiative (WPSI) guidelines, which include:
- Cervical cancer (Pap test) screening
- HIV screening
- Counseling for sexually transmitted infections
- Well-woman preventive visits, including prepregnancy, prenatal, postpartum, and interpregnancy visits
- Screening for diabetes in pregnancy (and after pregnancy in plan years starting in 2024)
The ACA also requires nongrandfathered plans to cover additional preventive services identified by the USPSTF. These include:
- Chlamydia and gonorrhea screenings in all sexually active women aged 24 and younger and in women aged 25 or older who are at increased risk for infection
- Syphilis infection screening in all pregnant women and in persons at increased risk for infection
- Preexposure prophylaxis (PrEP) for persons at high risk of HIV acquisition
Fertility services
Public and private insurers typically do not cover fertility services such as in vitro fertilization and egg freezing. Fertility treatments are costly. Payers do not view these services as being medically necessary even though such services are necessary for many people to achieve pregnancy. Fifteen states have mandated coverage of some infertility treatments, but these mandates apply to certain insurers, for certain treatment services, and for certain patients. A couple of states require insurers to offer policies with infertility coverage, but employers are not obligated to offer those plans. Notably, New York is the only Medicaid program that explicitly requires coverage of fertility treatment.
Sexual dysfunction treatments
Medicare Part D plans do not cover drugs used to treat erectile dysfunction (ED), unless they are prescribed for a different FDA-approved indication, such as pulmonary arterial hypertension. Many private insurers exclude coverage of ED drugs for sexual dysfunction, considering them as products for lifestyle enhancement or performance rather than medically necessary treatments. However, some plans may cover them if required by state regulations or if the plan sponsor purchases an optional rider.
Osphena, a drug to treat dyspareunia (painful intercourse) caused by menopause and treatments for low sexual desire in premenopausal women (e.g., Addyi and Vyleesi) are not excluded by Medicare — although private payers’ coverage of these products varies. Medicare is apparently unconcerned about any moral hazard associated with Osphena, and utilization by premenopausal women is less relevant to the Medicare population. In this case, the lack of restrictions reflects the absence of utilization and cost concerns.
The assumption that some men will overuse ED drugs led to awkward decisions regarding monthly quantity limits. Quantity limits of 4, 8, or 12 tablets per month translate to one, two, or three doses per week on average. This may sound funny to many, including some on P&T committees tasked with making quantity limit decisions. One study showed that less than 10% of patients exceeded their monthly quantity limit of six tablets, with approximately 80% of those patients paying for additional tablets out of pocket and approximately 20% appealing to the MCO for additional tablets. While the quantity limit likely suppresses some additional utilization as intended, is that reasonable?
Contraceptives
In 1998, a study of insurers in Washington State found that only half of the plans covered at least one contraceptive service or device, and that only 30% of plans covered all five core FDA-approved reversible methods including the IUD, diaphragm, hormonal implant, hormonal injectable, and the pill. Fast forward: With the implementation of the ACA, the WPSI guidelines now require coverage of 18 FDA-identified contraceptive methods, including emergency contraception, female sterilization and prescribed over-the-counter methods, at no out-of-pocket cost to the insured. Plans are not required to cover over-the-counter birth control methods (e.g., condoms, Plan B) when they are not prescribed.
Unfortunately, while the ACA requires most plans to cover tubal ligation, it does not require coverage of vasectomies. The stated reason, as per a footnote in the HRSA guideline, is that it is beyond WPSI’s scope. So, why has the USPSTF not recommended vasectomies? Nevertheless, several states have their own requirements for insurers to cover male sterilization.
Importantly, Medicare does not cover contraceptives despite covering approximately 1 million women of reproductive age (18–44). Further, objecting organizations based on religious beliefs or moral convictions and grandfathered plans are not required to cover contraceptive services. Celebrating broad contraception coverage prematurely may breed complacency.
Abortion
Coverage for abortion may or may not be offered by insurers and, predictably, its availability varies from state to state. State laws may limit or, conversely, require coverage by insurers. Some states ban abortion coverage by ACA marketplace plans and/or Medicaid.
Under Medicaid, abortion coverage is severely limited due to the federal Hyde Amendment, which prohibits federal spending on abortions, except when the pregnancy is a result of rape or incest, or when the life of the pregnant person is in jeopardy. States may use their own unmatched funds to pay for abortions for Medicaid enrollees in other circumstances. The Hyde Amendment also restricts abortion funding under the Indian Health Service, Medicare, and the Children’s Health Insurance Program, and similar restrictions apply to the TRICARE program, federal prisons, the Peace Corps, and the Federal Employees Health Benefits Program.
Gender-affirming care
Many plans do not cover gender-affirming care, including hormonal treatments and surgical services for gender dysphoria. These services may be referred to in medical policies using different terms, such as “sex change” or “sex reassignment.” The coverage landscape for gender-affirming care has become increasingly polarized across states, with a growing number of states either limiting or banning access for young people. In contrast, other states have taken steps to protect access to such care. Not surprisingly, this divide perfectly correlates with partisan leanings in states (i.e., whether congressional and gubernatorial election outcomes make them Republican-leaning or Democrat-leaning), indicating a political and philosophical influence. While the costs of this care can be significant, economic considerations are not at the forefront of this debate.
Embracing change
Coverage for sexual and reproductive health continues to expand and contract. Martin Luther King, Jr. once said, “The long arc of history bends towards justice.” We can only hope that’s the case.
It is naïve to think federal and state politicians would leave sexual and reproductive health decisions up to patients and their providers. These issues often become battlegrounds where politicians take positions to secure votes and donations. Politics will inevitably shape access to the more contentious sexual and reproductive health care services where passions run high.
Economics should not be the enemy of fair and equitable access to sexual and reproductive care. While concerns about moral hazard may be raised to restrict access to some services, the hazards of morals, that is, the unintended consequences of forcing one’s personal beliefs upon others, should be of great concern. Unintended pregnancies, depression, and suicide are among the hazards of morals.
When making sexual and reproductive health coverage decisions, it is important to approach the discussion with love and compassion. Love and compassion will help to ensure that everyone has access to the sexual and reproductive health services they need.
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