Proposed law could have far-reaching effects
Would EPICC right inequity in health coverage?
It started with Viagra. Last year, after published studies confirmed the efficacy of the drug as a treatment for male impotence, many health care experts were surprised at the speed with which some insurers agreed to cover the cost of the medication. Thatbecause - in some cases - the same insurers had steadfastly refused to cover contraceptive drugs and devices for women.
Now, lawmakers at both the state and federal level, with the support of the Washington, DC-based American College of Obstetricians and Gynecologists (ACOG) as well as family planning advocates, are pushing for passage of a new law. The law would require insurers who include prescription drug benefits in their plans to cover all FDA-approved contraceptive devices and outpatient services.
While the issue may sound like a battle between managed care organizations and their plan members, ethics committees could find themselves in the center of a battle over medical necessity involving regulatory agencies, payers, and patients.
The Equity in Prescription Insurance and Contraceptive Coverage Act (EPICC), say supporters, will help remedy an unequal health care cost burden for women, as well as reduce the number of unintended pregnancies, pregnancy-related complications, and abortions in the United States. (For more on federal and state legislation, see story, p. 115.)
Some health care experts note, however, that legislation compelling insurers to offer this service invariably will cause insurance premiums to rise and may result in some smaller insurers dropping their prescription-coverage benefits.
Law seeks to remedy inequality
According to ACOG estimates, women pay 68% more in out-of-pocket health care costs than men, primarily due to the cost of reproductive health care services.
Two-thirds of U.S. women of childbearing age (15 to 44) rely on employer-related health plans for their health coverage. According to a 1994 report by the Women's Research and Education Institute and the U.S. Department of Health and Human Services, 90% of those plans cover prescription drugs, but a large majority of them exclude con traceptive drugs and devices from the benefit.
What's more, 49% of traditional indemnity plans and preferred provided organizations don't cover the five most popular forms of reversible contraception. Those methods of contraception are: the pill, the intrauterine device (IUD), Depo-Provera, Norplant, and the diaphragm. Further, 40% of PPOs only cover oral contraceptives. Thirty-nine percent of HMOs routinely cover all five of the most common birth control methods.
In testimony before a congressional committee considering the EPICC legislation, ACOG's immediate past president Richard Schwartz, MD, argued that insurers unfairly reap the economic benefits of contraception use without assuming the costs.
Family planning prevents other, more expensive medical conditions associated with unintended pregnancy, such as spontaneous or induced abortion, maternity care and delivery, and perinatal and maternal morbidity, he argues. "Despite the fact that effective use of contraception provides great savings to the health care system, it is the individual woman who is shoul der ing the burden for these cost savings to insurers," he told the committee.
Contraceptive services traditionally haven't been covered because they were seen as "discretionary," says Jay Wolfson, professor of health law and finance at the University of South Florida in Tampa.
Other motives for excluding contraception included the extra cost of paying for prescription drugs and devices for so many women, and the potential liability.
"If my wife and I decide that she is going to go on birth control pills, and the plan does cover the cost for it and it fails, or we have an untoward event, like a pregnancy or a complication, one of the things you see happening now is that people are suing anyone nearby with deep pockets, including the insurance company," Wolfson says.
Are they necessary?
Coverage of Viagra necessitated a re-exam ination of that thinking, he explains. There is a question of choice and whether all services associated with conception and childbearing are - or should be - medically necessary, he notes.
"The whole question of the scope of prescription drug coverage has come up in large part because of the effects of Viagra in the marketplace. If you are going to cover Viagra for males for impotence, then the opinion all along at tables that I have been sitting at is, 'You must cover contraceptives as well.'"
The issue was debated at particular length at the first meeting of the Baltimore-based Health Care Financing Administration's price and review commission, on which he serves, says Wolfson. "The natural question is, if you are covering fertility services for men, should you not cover infertility services for women?"
Some advocates, however, contend any debate over the medical necessity of contraception is faulty even without the discussion about Viagra.
"There is nothing optional about contraception," stated Luella Klein, MD, ACOG's director of women's health issues, addressing members at the college's recent annual meeting. "To ignore the health benefits of contraception is to say that the alternative of 12 to 15 pregnancies during a woman's lifetime is medically acceptable."
According to a recent report commissioned by the Alan Guttmacher Institute, a New York City-based, nonprofit reproductive health research group, the increase in premiums to cover contraceptive benefits would be minimal.
According to the report, Cost of Employer Health Plans of Covering Contraceptives, the estimated maximum added cost of covering the full range of FDA-approved reversible medical contraceptives in plans not currently covering them would be $21.40 per employee per year. Of that figure, $17.12 would be employer costs, and $4.28 would be employee costs.
Though that may not seem like much, the proposed law would function as another federal mandate on all health plans with a potentially surprising impact, says Maxwell J. Melman, JD, director of the Law Medicine Center at Case Western Reserve University in Cleveland.
"We've seen this before, with the mandatory 48-hour maternity stay," he states. "What's happening is Congress is frustrated, and the country is frustrated because there are these sort of hard-to-defend gaps in coverage - such as allowing new mothers six hours in the hospital or not covering contraception - that we are beginning to see addressed in legislation. The question is, what's next?"
Eventually, if Congress continues to legislate individual benefits, the country will end up with what amounts to a national health plan, a standard set of benefits to which everyone is entitled, Melman asserts. The potential problem is that there is no cohesive cost vs. benefit debate about which services will be covered, he says. "It's simply whatever gets us sufficiently annoyed."
Although an additional $21 per month may not sound like much of an increase, he says, what happens when more and more mandates are handed down? "This is number two. By the time you get to number 23, you are talking about a significant ratcheting up of insurance costs."
At the margin of the market, some insurers will opt to abandon covering prescriptions altogether rather than trying to absorb or pass on the cost of covering contraception, he says. "Any economist will tell you, if there is an escape valve, there will be an effort to avoid paying for this kind of benefit. It's hard to plug all of the loopholes."
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