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The “War on Women” has gotten out of hand

The “War on Women” has gotten out of hand

Last updated on: July 5, 2014 at 11:59 pm by Jane the Actuary

The “War on Women” has gotten out of hand 2014-07-05T23:59:00-06:00 Jane the Actuary

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So just how many “sky is falling” articles have your socially-liberal friends on facebook shared? Because you know that, if you tend to read socially-conservative websites, you still get your daily dose of liberal ideology that way, even if you don’t happen on any given day to stop by and see what clickbait Slate has to offer.

(Today, George Takei had a picture of two weepy men holding an infant just born to a surrogate they had contracted with; it was a fairly odd photograph as the men were shirtless for no discernable reason — my guess was that they’d just been in the birthing tub or that the photographer thought the photographs would be more artistic that way, but it makes them more artificial and more creepy than moving. But I digress.)

The core, fundamental idea seems to be that women are uniquely disadvantaged by virtue of their ability to become pregnant, so the world at large must compensate for that. Activists are conflating the opportunity to obtain contraception with no out-of-pocket cost with its access in the first place, and are taking it for granted that the natural order of things is for contraception to be a part of an employer-provided healthcare plan.

But what, really, is the rationale for mandating its inclusion, specifically with no out-of-pocket cost?

According to the feds themselves, in the official regulations,

Individuals are more likely to use preventive services if they do not have to satisfy cost-sharing requirements (such as a copayment, coinsurance, or a deductible). Use of preventive services results in a healthier population and reduces health care costs by helping individuals avoid preventable conditions and receive treatment earlier.

And what are the preventive services, other than contraception?

According to the official list, developed by the Institute of Medicine, it’s mostly a lot of screenings: for high cholesterol, high blood pressure, depression, diabetes, and certain other ailments. Some preventive measures, such as low-dose aspirin (as if the cost of something as cheap as aspirin makes a difference in compliance with a daily regimen), some booster-type vaccines, and weight-loss counseling and smoking cessation counseling and treatment. (Interesting that only counseling is covered for weight loss for those at risk, but smoking cessation treatment is covered. Consistency would dictate that treatments be covered for both or neither — does this mean that the Institute made the compromise of concluding that it’d be opening up a can of worms in declaring weight-loss treatments covered at no out-of-pocket cost, or that smoking is more dire than obesity in terms of health risks?

For children, too, the list consists mostly of screenings, plus vaccinations, and a small number of ongoing preventive treatments: fluoride supplements where water is unfluoridated, and iron supplements for infants with low iron levels.

For women, specifically, there are additional recommended screenings such as for gestational diabetes. And then, the Big Two:

Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women” and

Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs).

(Of course, “abortifacient drugs” means very narrowly, in the feds’ definition, drugs exclusively intended to produce an abortion, which means that they shouldn’t even be implying that it’s a “contraceptive method” in the first place.)

This context really makes the contraceptive mandate very out-of-place, given that most of the other items on the list ought to be a part of a single routine check-up, and that I would expect that the biggest issue with cost-related patient non-compliance is really more with first-line treatments than with these basic screenings: wasn’t the paper full of stories of grateful new Obamacare enrollees with diabetes or high blood pressure or other ailments who were headed towards health crises because they couldn’t afford their medications or ongoing doctor visits?

So what’s the rationale for requiring coverage of contraception?

My memory was that the statement was, no, of course being pregnant isn’t in itself a disease we need to prevent, but too-closely-spaced pregnancies are — which would warrant no-out-of-pocket-cost contraceptive coverage for women who had recently given birth but not all women, universally.

But according to the regulations I dug out today, it’s only partially about spacing and mostly about unplannedness:

Women experiencing an unintended pregnancy may not immediately be aware that they are pregnant, and thus delay prenatal care. They also may be less motivated to cease behaviors during pregnancy, such as smoking and consumption of alcohol, that pose pregnancy-related risks. Studies show a greater risk of preterm birth and low birth weight among unintended pregnancies. In addition, contraceptive use helps women improve birth spacing and therefore avoid the increased risk of adverse pregnancy outcomes that comes with pregnancies that are too closely spaced.

I’m not sure if I buy this. In the first place, “prenatal care” doesn’t really start until the second trimester — or, at least, I remember being all excited about being pregnant the first time around and calling to make an appointment, and being surprised that the receptionist was in no hurry to schedule me. I would also expect that there’s a substantial correlation between low-income women and both unplanned pregnancies (both in terms of true unwanted pregnancies, and a more generally lack of interest in trying to time pregnancy for a specific time) and smoking and alcohol use.

And here’s the kicker: “free” contraceptives are promoted as a money-saver:

Covering contraceptives also yields significant cost savings. A 2000 study estimated that it would cost 15 to 17 percent more not to provide contraceptive coverage in employee health plans than to provide such coverage, after accounting for both the direct medical costs of pregnancy and the indirect costs, such as employee absence. Consistent with this finding, when contraceptive coverage was added to the Federal Employees Health Benefits Program, premiums did not increase because there was no resulting net health care cost increase.

The publication gives references for each of these claims, though I presume they’re behind paywalls or otherwise inaccessible. A 15% – 17% cost increase in not providing contraceptive coverage in employee health plans? That seems to be a hypothetical calculation based on a model, assuming women are more likely to use less reliable contraception and have more children on average, if contraception isn’t covered. These studies also speak of coverage of contraception in general, not specifically the “no-out-of-pocket-cost” requirement now being imposed.

Ann Althouse, in her comments within her post on the topic, takes the approach that every woman is going to have some fixed number of children in her lifetime, so that the goal of free contraception is to move women onto more long-lasting contraception so that they have their children later in life (though not so late, presumably, as to make these planned pregnancies high-risk due to “advanced maternal age”). Arguments on cost savings assume the opposite, that women will have fewer lifetime children, when they say that an IUD is cheaper than childbirth expenses (because, let’s face it, a marginal reduction in the number of high-risk pregnancies isn’t going to drive costs down this much). Which is right? I don’t know. But the behavior of low-income women is not terribly relevant to employer-provided healthcare plans.

But at any rate, are contraceptives covered because the administration figured it would be a good weapon to bludgeon Republicans with? Probably not. It looks much more like the Public Health crowd saw in the “preventive care” guidelines an opportunity to push an agenda of greater contraceptive use, and more widespread use of long-lasting, no-compliance-required contraceptives, and ran with it.

And here’s a final, tangential irony of the “free contraception” rule: it will destroy any hope of developing a “male pill” as the market for it will be virtually nil, given the human tendency to choose the “free” option even if the with-cost option is really the better choice.

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