Trojan Plan

By 2014, women with health insurance will be able to get condoms with a prescription, free of co-pay. Men, on the other hand, will have to pay for them.

This isn't the only thing women will get included in their premiums. The list includes HIV screenings, breast-feeding pumps, pap smears, and sterilization surgeries. Anything the Department of Health and Human Services (HHS) deems preventative care for women will be free. The reason: Women of reproductive age pay 68 percent more in out-of-pocket health costs than their male counterparts, most of it for reproductive care. They bear most of the costs of birth control. To address this disproportionate financial burden, the HHS announced new rules requiring that health-insurance companies cover the cost of women's preventative care, including contraceptives. In solving one problem, though, the requirement may create another: Men will still have to pay for services related to contraception and sexual health. The question becomes, if men have to pay for condoms, for example, and women don't, why would men buy condoms?

The new rules come out of an amendment to the health-care law, which mandated that several areas of preventative medicine be covered free of charge but left out issues specific to women. So Senator Barbara Mikulski of Maryland introduced the women's health amendment. Improved access to contraception is an important piece of health care for women. Planning and spacing apart pregnancies is healthier, and women who are able to do so tend to be wealthier and more educated. One-third of women who could become pregnant either forgo contraceptives or use them sporadically because of their cost.

In issuing the rules on what was to be provided without patient cost-sharing, HHS listed all "FDA-approved contraception methods." For most plans, this will begin in 2013. Women's health advocates had hoped that the Mikulski Amendment would lead to fully covered contraceptive care, but the roundabout way this happened meant it won't be free across the board. Culturally, the responsibility to prevent a pregnancy -- or spread of sexually transmitted infections -- lies with the woman. Now, with economic incentives in the mix, women may find themselves solely responsible for birth control while their boyfriends, husbands, and even one-night-stands are off the hook.

"Women do already bear the primary burden to get birth control in the U.S.," says Judith Baer, a professor of political science at Texas A&M University who has written extensively on women's reproductive rights. There's reason, though, to think that trend was shifting toward a more balanced approach. That's particularly true with condom use. Since HIV has become a serious risk, men have become more proactive about buying condoms; more than any other form of birth control, condoms are a shared responsibility. Under the new rules, however, where women can get prescriptions for condoms but men have to buy them, Baer says, "there may be a shift in responsibility to almost exclusively women."

Michael Kimmel, a professor of sociology at the State University of New York, Stony Brook, whose research focuses on men and masculinity, adds: "My sense is that this is a wrinkle that acknowledges that women have been historically responsible for birth control, and that men's use of condoms has been about HIV, not birth control. Providing it free for women but charging men may actually subsidize male irresponsibility."

Condoms, though, aren't the only form of birth control women may become responsible for acquiring. Perhaps the biggest change would be in sterilization. According to the Guttmacher Institute, sterilization is used by 27 percent of women who use contraception, making it the second most popular form of birth control after the pill. For women over 35 years old, sterilization is the preferred method of birth control; for women 40 to 44 years old using a form of birth control, half have been sterilized. The procedure is particularly popular among black and Hispanic women, women in poverty, and women without a college degree, all of whom are less likely to rely on their partner getting a vasectomy or to use the pill.

But many partners do choose vasectomies. Vasectomies are far cheaper, safer, and have more minor effects than tubal ligation, the female sterilization procedure. Under the new rules, where only female sterilization is covered, women may begin using sterilization more than they already do. "The logical decision from an economic perspective is she gets the tubal ligation rather than he getting the vasectomy," Baer says. "It's definitely a potential issue," says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, "and tubal ligation rates are already three times higher than vasectomy rates."

If the new rules put more pressure on women, they aren't exactly easy on men, either. According to Sonfield, the rules aren't written to incorporate any services for men, who will continue to pay some amount for vasectomies, condoms, and other health screenings and counseling. Baer suggests that activism around this issue could eventually result in a rule change. HHS has changed its policies in the past when, for example, women realized that Viagra was covered by many insurance companies but oral contraceptives were not.

Barring a rule change, it's largely up to insurance companies as to whether they will offer the same services to men or follow the strict letter of the law, Sonfield says. If they don't cover men, then eventually other health-care law requirements could expand to include contraception for men. For example, if a male birth-control pill is developed -- something that may be ready in the next few years -- then that could be incorporated into another area of preventative care covered under the health-care law. After all, HHS sets these rules and can change them at any time.

In fact, the whole point of health-care reform is that it would lead to a gradual increase in access to health care. Liberals dissatisfied with the health-care law for not doing enough comforted themselves that our most successful social programs, Social Security and Medicare, began as narrow programs that expanded over time to include huge swaths of the population. They now hope that the Affordable Care Act, imperfect as it is, will be the first step toward universal health care. Contraception will be one way in which we see that hope play out; the law could end up narrowing services for men while placing all the responsibility on women, or it could lead to covered contraceptive care for everyone. "I consider the new rules a very welcome change," Baer says. "It may have an effect of shifting a greater burden to women but also greater autonomy."

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