The tweet below has bugged me for a week as it is glib and ignores incentives.
Let’s work the assumption that insurers will pay if they are either contractually and legally obligated to pay for something OR the thing that is getting paid for is the least expensive option to fulfill legal and contractual obligations.
What is the economic rationale for any given insurer to pay for a vasectomy?
The tweet proffers it is to prevent pregnancy and from the insurers point of view, to prevent paying for labor and delivery costs.
That sounds reasonable, but let’s really start unpacking some of the return on investment funnel here.
- Vasectomies are for men. The insurer is guaranteed to be paying for the vasectomy. They are not guaranteed to be paying for any pre-natal care, or labor and delivery costs of the pregnant woman. The insurer might be paying for another insurer’s avoided claims. There is a substantial probability that the woman who becomes pregnant if a man does not have a vasectomy is not covered by the same insurer. Just under half of all births in the US are paid for by Medicaid. It is not unusual for a household to have multiple insurances. It is not a guarantee that the woman and man are a legally bound insurance unit (marriage or domestic partner). It is not a guarantee that the woman who becomes pregnant is even the spouse or partner of the man who otherwise would have had a vasectomy.
- Vasectomies are not super cheap. Typically they cost between $1,000 and $3,000. This runs into a churn problem. Individuals routinely switch insurance companies every one to three years. In the ACA, median enrollment duration is just 13 months. A big expense with a short pay-off window is often not a net cost-saver.
- Other medical options exist. If an insurer wants to minimize unanticipated pregnancies that it pays for, there are plenty of other options that don’t run into churn problems. The most effective is female controlled long acting reversible contraceptives (IUDs, hormone implants etc). IUDs are good for at least an entire churn cycle and cost on average less than a vasectomy while also being a legally mandated coverage requirement. Oral contraceptives are less effective but cheaper on a short contract duration. These are all targeted at the person who will be pregnant in case of a birth control failure. It is more targeted and more direct.
- Non-medical options exist: There are plenty of ways for men to not get their partners pregnant without a vasectomy while also having a mutually satisfying sex life. We already discussed some of the medical options above. There are also timing, pulling out, fingers, oral, anal, toys, gels, diaphragms, female condoms, male condoms and many other things that I am sure you can think of.
- Selection — men who want vasectomies (myself included) have self-identified as be willing and able to take steps to minimize pregnancy risk. If a vasectomy is not available, they are still more likely to have steps in place to minimize pregnancy risk.
- Quality of Sex Life versus Medical Issues For individuals who want a vasectomy and have self-identified as likely to be taking the appropriate steps to minimize pregnancy risk , vasectomies are quality of sex life improvement. Vasectomies make Round #3 and wake-up sex far easier as one does not need to dig into the back of the condom drawer for the last condom that might have been forgotten there months ago.
So the insurer is not guaranteed to actually accrue savings from a not super cheap procedure for a population that is fairly unlikely to generate unexpected claims when there are both more targeted, cheaper AND legally required services available and the vasectomy is primarily a quality of life improvement rather than a health improvement.
Why should an insurer want to make this cost-free to the patient?
Trivia Man
Thanks, that is a good way to look at it. A snarky framing might be “the potential vasectomy patients who may become pregnant at a later date is 0%”
Trivia Man
Of course that ignores the pool of “potential vasectomy patients who may use their insurance to cover a pregnancy at a later date” which is certainly not 0%
Nate Combs
When I got my vasectomy, the clinic quoted $3000 with insurance, but if I was willing to pay cash, they’d only charge $1200.
I always thought that was funny, as if I was a powerful collective bargainer of “one”.
justawriter
Don’t forget those men whose personality is a 100% effective means of birth control.
David Anderson
This is fundamentally a Number Needed to Treat problem where the NNT is substantial and expensive for each avoided pregnancy that the insurer has to pay for.
Doug R
Why is the average enrollment 13 months? That’s no way to ensure stability. I guess this is why we have better coverage with our Commie Canadian Coverage™
Geo Wilcox
The way the Christofacsists are coming for any female birth control means #3 might not be an option going forward. There is that to seriously think about when it comes to men getting clipped.
Martin
I mentioned this to my wife OB after her second pregnancy. Her first was pretty challenging – 4 months of bed rest and a month premature. When we decided to go for a second, her doctor said ‘Ok, but here’s the deal – you’re on bed rest the moment you get a positive test, and we’re sewing your cervix shut to keep it in there’. Our second was two months premature, but we got her over the line. Her OB said there’s no way you’ll be able to do this a third time. That second probably probably cost upwards of a million dollars between the collections of machines we had for home monitoring, the weekly home nurse visits, the two week hospital stay after her water broke at 30 weeks, and the week and change in the NICU for my daughter. A free vasectomy for me, my neighbors, and the mailman (just in case) would have been money well spent relative to the Manhattan Project scale lift involved in a third pregnancy.
Plus, it was during my V procedure that we figured out I probably had the MC1R mutation that makes me resistant to painkillers/anesthesia – later confirmed by a work colleague. During that procedure I mentioned to my ginger doctor that I was nervous because locals don’t usually work great and, well, I would probably notice this. Since he had the MC1R mutation, he took this seriously and we had a nice little chat to start. See, I have a shit-ton of redheaded relatives, but I’m not a redhead myself, so I got passed the resistant to painkiller gene, but not the red hair one. Gave me a bunch of recommendations on what to tell doctors going forward so I don’t have to suffer through procedures as much.
Another Scott
@Martin: Good to see you posting again. I hope things are going well.
Interesting story, also too!
Thanks.
Cheers,
Scott.
Ken
@Nate Combs: Possibly the clinic knew the insurer would only pay a negotiated price of (say) $1000, so the $1200 cash was better.
Argiope
Not to be flip, but all of this is a great argument for a single payer system. Vasectomy is the single most effective contraceptive there is, and for those who want permanency, it’s much less risky and much more effective than female sterilization. Not everyone can use hormonal methods that are long acting and reversible. The public health good of reducing undesired pregnancies goes beyond the possible cost-benefit ratio of any single insurance company’s calculation for their members.
caphilldcne
To answer David’s question, isn’t the ultimate answer here that if the insurers cover a range of multiple options and all the insurers cover it, that it brings down the price for everyone resulting in fewer unplanned and expensive pregnancies. In short, that’s the whole purpose of insurance. But I do agree. The tweet is incorrect regarding where and how savings occur.
lowtechcyclist
Every now and then, I used to argue for single-payer birth control: just have the Federal government pick up the tab for whatever legitimate form of birth control you want to go with: ‘the pill,’ implants, Plan B, mifepristone, vasectomy, hysterectomy, whatever.
Still seems like a good idea to me. I understand that getting to a single-payer system across the board is a heavy lift and may never happen here. But just for birth control? Sure, why not? And right now, with the side benefit that states wouldn’t be able to ban any of the above.
Eolirin
@lowtechcyclist: You don’t need single payer for that at all. The ACA already has regulations that force no-copay service provision, those can be expanded to cover more things, though we need to get the Hobby Lobby ruling reversed, and there are mechanisms that can provide revenue stabilizers for the increased cost.
Roger Moore
@Doug R:
A lot of people only wind up on the exchanges because their regular insurance has been disrupted. They might be between jobs or starting with an employer who doesn’t cover their employees until they’ve passed their 6 month probationary period, or something like that. They buy coverage on the exchange as a stopgap until their preferred option of coverage through their employer becomes available. That kind of thing leads to a lot of churn.
Roger Moore
@Geo Wilcox:
There’s been a surge of interest in vasectomies precisely because people are worried about continued availability of contraceptives.
Roger Moore
@Ken:
Yeah, medical pricing in the USA is complete nonsense. The listed prices for medical procedures represent what the providers wish they could charge, and nobody with any kind of negotiating power pays anything close to that.
lowtechcyclist
@Eolirin: Wouldn’t single-payer birth control solve the Hobby Lobby problem? Might be awhile before it’s reversed.
David Anderson
@Argiope: The churn and “SEP” field problems disappear in single payer, but the “is this cost effective and targeted relative to LARCs/tubes tied” and “do we want to pay for more middle age couples getting middle of the night quickies in” questions remain
David Anderson
@Doug R: For the ACA, the individual market is designed to be the coverage of almost last resort. Once someone has a “reasonable” offer of something else, the subsidies turn off. And offers of something else are common — someone gets a new job, a partner gets a new job, income changes so there is a Medicaid qualifying event, people move etc.
Ruckus
@lowtechcyclist:
Birth control does 2 things that conservatives detest. It allows women to decide they do not want children or too many children and that is at least seemingly against all conservative concepts – more tax payers so that the uber wealthy don’t have to pay, and actually having women control their bodies or men not having those 8-10 kids and keeping conservative politics well supplied with bodies.
OK, yes I’m being a bit snarky but really, how is it possible not to be snarky talking about conservative policies? The world grows, evolves, and it’s not like there isn’t more than enough of us taking up all the oxygen on the planet.
buskertype
@Argiope: thank you. exactly. The ACA was a big improvement over the non-system we had before, but it’s still bullshit.
Martin
@Roger Moore: I’m on the exchange during my gap from retirement until Medicare kicks in. For a lot of people that’s just a year or two.
Joshua Todd
I think insurers should cover everything 100 percent. I am sick of the nickel and diming BS and copays.
Argiope
@David Anderson: How so? Right now we are over utilizing a more expensive and less effective procedure (tubal ligation) to reach the same ends.
ETA complications from tubals alone likely make the $ math work if more men could access vasectomies, but when we add in the costs of unintended pregnancies and their higher risks for complications, seems like it’s a no-brainer. But I’m a clinician, not an insurance expert.
Hob
@David Anderson: I think your snark level may have started getting in the way of your argument at this point; the “why should we pay for middle-aged couples having a quickie” joke in your last comment is contradicted by the other half of your comment, since if you’ve already decided tubal ligation is a worthwhile procedure, then that’s accomplishing the same thing in the context of a long-term relationship so it’s silly to complain that it is allowing couples to have sex without barrier contraception. Which is a really odd thing to complain about anyway! I mean… as someone who had a vasectomy after I was 100% sure children were not a goal, I can tell you that “I won’t have to go through the inconvenience of reaching for a condom in the middle of the night” was nowhere near my top reason. The top reason was that I didn’t want to have children or take the chance of ever knocking someone up if, as can happen, other birth control methods failed. You can easily make your point about insurers’ cost calculations without adding the weird idea that vasectomies are inherently some kind of frivolous whim by lazy people. Or not, whatever.
Suzanne
@Doug R:
Because people change jobs a lot.
Martin
@Argiope: It is a great argument, however, the path to single payer requires a period of regression before the benefits are seen, which is a major problem for policymakers that we need to learn how to address.
See, single payer requires dismantling the existing systems, such as they are, and that will involve a massive amount of administrative work to transition literally every American to this system, plus every medical institution. During that period you’re basically paying for both systems to co-exist, so it will be considerably more expensive, and the outcomes during this period will in many cases be worse. For instance, you’re going to eliminate about a million jobs (quite possibly including our own David’s here). You have to address that.
This transition period is a vulnerability for the system because anyone who is not invested in the system (for instance, every Republican) is incentivized to undermine it, and those costs and worse outcomes are going to be highlighted at every turn. They will make decisions to stall its implementation, try to defund it, and use it to put themselves in power where they can do all of this more effectively.
So while we can see that it would clearly be better ‘over there’, it still requires a path to get there, and that path is harder to figure out than the actual single payer system. This is the ‘go to market problem’ for policy making.
It’s why the US has so much trouble doing major infrastructure projects – because they take long enough to implement that they become obvious environments for conflict to develop. This is why nuclear is a non-starter for climate change – it has a terrible path to implementation compared to solar/wind, etc. In the decade it takes to build it churns out a mountain of CO2 just from the concrete alone, while providing no benefit. And if it doesn’t get built because politicians are fighting, some contractor goes out of business, etc. then the whole thing turns into opportunity cost.
Suzanne
@Martin: Very glad you are back.
Baud
@Martin:
Welcome back.
Hob
And like Argiope said, it’s also unclear what you are even arguing when you bring up tubal ligation– that’s far more expensive, how could it be considered more cost-effective? Not to mention that it’s also far more intrusive, which was a factor in my and my partner’s decision.
The only way I can make sense of this is if you’re saying that a woman is more likely to be on her own same insurance policy if she gets pregnant later, so it’s logical for her insurer to pay for a tubal ligation, whereas a man getting a vasectomy might otherwise have knocked up someone who’s not sharing his policy. Except you’ve already also pointed out that most people don’t stick with one insurer for very long (and not just when an ACA exchange is involved; every company I’ve worked for in the last 10 years has changed coverage out from under me at least once), so “will we be covering this same person for the rest of their life” is not a realistic standard.
Roger Moore
@lowtechcyclist:
It would create an even bigger problem. If the people opposed to birth control ever took over the government, they could shut down all access to birth control to everyone without having to overturn Griswold.
Eolirin
@lowtechcyclist: Maybe, but I honestly don’t trust single payer in our current political environment; even putting aside all the transition issues, we’re one bad election away from a Hyde like ban on abortion or birth control coverage that now impacts everyone in the whole country, or for some other broad fucking with the healthcare system.
As much as it can suck when stuff gets kicked back to the states, it also minimizes damage when stuff gets kicked back to the states; NY and CA and MA can set effective standards even if the federal government starts going off the rails, etc.
Ohio Mom
@Martin: Good to see you again, hope you stick around, I missed your perspective and informed comments.
On another note, add me to the list of people pointing out that this is a made-up problem, if we had single-payer health coverage like a decent nation state, this post would never have been written.
Eolirin
@Ohio Mom: Most countries with universal coverage aren’t single payer, so this remains a problem that needs to be solved and can be solved without going there.
eldorado
i like the optimism regarding round #3
Roger Moore
@Eolirin:
The flip side is that it minimizes the benefits when the Democrats are in charge. Look at all the states that resisted Medicaid expansion, for instance; if Medicaid were a national program instead of a state one, that wouldn’t have happened. In practice, the Republicans have been reluctant to seriously undermine popular national programs like Social Security and Medicare.
Ohio Mom
@Eolirin: You are right, I am apt to mix up single-payer and universal coverage when I am not thinking, and they are very different.
But I might also argue that it makes no difference which term I use because I have no hope of seeing either one instituted in this country of ours.
Central Planning
I think your #3 doesn’t really work in your list of alternatives. If men don’t want to have babies, why is that responsibility now back on the women to take birth control? That seems unreasonable to me.
I got a vasectomy (I am the owner of a nice little vasectomy?) years ago. If I were single, I would want one so I don’t accidentally become a father again. I’m sure there is a small population people out there who claim to be on birth control but really aren’t so they can get pregnant (I have no evidence for that). How can you really trust them if you both want a one night stand? (in that case I would also recommend a condom)
Finally, #4? How effective are some of those methods? Pulling out looks to be about 80% effective (i.e. 1 in 5 end up becoming pregnant). The rhythm method is about 75% effective at preventing pregnancy. If I wanted to remain footloose and fancy free without child support, I would absolutely not use those methods.
I guess to wrap it up (see what I did there?): I think more birth control methods are better for everyone… a belts and suspenders approach.
ETA: On the financial piece and 13 month enrollment duration – sure, an insurer might lose some customers that got vasectomies. But aren’t they also gaining customers that already had vasectomies? Does it net out to $0 over time for any given insurer?
StringOnAStick
@Martin: That’s what I did; Medicare starts for me on July 1.
Sparks
@Roger Moore: I got a $3,000+ bill from a fire district for transporting me to an ER and yelling ”are you drunk?” When it was an epileptic seizure. And I thought my insurance would cover most of it.
ETA: actually I have at least three of them.