David Engler was pretty sure he didn’t want kids until a frustrating day at school two years ago sealed the deal for the now 43-year-old substitute teacher.
“It was wild. I had to call the office seven times to get the kids out,” he said. “The next day I called Kaiser and said, ‘I’d like to know how much a vasectomy costs.'”
A representative from Engler’s insurer, Kaiser Permanente, told him the procedure would be free because it was a form of birth control, he said. But after to undergo a vasectomy Last winter he received a bill for $1,080.
“I felt defeated, betrayed and frustrated,” said Engler, who lives in Portland, Oregon.
Engler’s experience shows how a maze of insurance coverage rules reproductive health care creates confusion for patients. Oregon requires that vasectomies be covered for most people who work in the public sector. But the federal Affordable Care Act — which requires most health plans to cover preventive health services, such as contraception, at no cost to consumers — does not require that vasectomies be covered.
And the confusion surrounding reporting could become even more complicated.
An ongoing federal lawsuit aims to overturn the ACA‘s preventive care coverage requirements for private insurers. If the case overturns the mandates, state-level laws — which vary widely across the country — would carry more weight, a change that would resume the “Wild West” dynamic of before Obamacare, said Zachary Baron, a health policy researcher at Georgetown Law.
It would create an environment “where insurers and employers are picking and choosing what services they want to cover or what services they want to charge for,” Baron said. “It would certainly threaten access to care for millions of Americans.”
Research has shown that requirements to cover preventive care have reduced consumers’ out-of-pocket costs and increased their use of preventive care. short and long term birth control methods.
The task of determining which contraceptive services should be covered falls to the Health Resources and Services Administration, or HRSA. Two other groups — the U.S. Preventive Services Task Force, or USPSTF, and the Advisory Committee on Immunization Practices, or ACIP — make recommendations about other types of care the ACA requires insurers to cover.
The plaintiffs in the lawsuit, a group of Christian-owned individuals and businesses, allege that the members of the three panels were improperly appointed by Congress. They also say that the recommendations for insurance plans to medication for HIV prevention violate their religious rights.
On June 21, the U.S. Court of Appeals for the 5th Circuit issued what it called a “mixed bag” ruling in the case. It said that one group — the USPSTF — had not been properly appointed, and therefore the recommendations it made after the ACA was signed into law were unconstitutional. The plaintiffs had asked for a nationwide injunction, but the court said only the plaintiffs’ organizations could be exempt from the recommendations.
The court then remanded the plaintiffs’ objections to the HRSA and ACIP recommendations — including those on contraception — back to a lower court for consideration.
The case likely goes to Reed O’Connor, a federal judge in Texas who has issued rulings undermining the ACA, including one that invalidated the entire law but was later overturned by the U.S. Supreme Court.
“O’Connor is a judge who is notoriously hostile to the Affordable Care Act,” said Gretchen Borchelt, vice president of reproductive rights and health at the National Women’s Law Center. “He’s someone who is willing to impose sanctions when he’s going to deny everyone in the country access to care based on what happens in one situation.”
She feared that a victory for plaintiffs could lead to confusion about which contraceptives are covered and how much they cost, ultimately leading to more unwanted pregnancies, all at a time when women have less access to abortions.
Nearly two dozen organizations, including the American Medical Association, the American Public Health Association and the Blue Cross Blue Shield Association, have joined Borchelt’s group in filing written comments warning of the potential disruption a ruling could cause for plaintiffs.
Jay Carson, an attorney at the Buckeye Institute, a conservative think tank, said he welcomed the court’s ruling. His group, along with the state of Texas, filed briefs in support of the plaintiffs.
“Unelected bureaucrats” should not have the power to decide which insurance plans are required to be covered, Carson said. “We have strayed so far from Congress actually making the laws and instead relying on Congress to give an agency the power to do the heavy lifting.”
The agencies’ remaining power is likely to be curtailed following a June 28 U.S. Supreme Court ruling that overturned a decades-old precedent that required courts to defer to federal agencies when making regulatory or scientific decisions.
“Courts will be able to scrutinize experts more,” said Richard Hughes, a health care regulatory attorney at the firm Epstein, Becker and Green. “It’s a shift in the atmosphere — we’re moving toward an administrative state that’s being contained.”
If federal coverage requirements for contraception were eliminated, states would be allowed to decide for themselves which services health insurers must provide.
Fourteen states and Washington, D.C., currently protect the right to contraception. But states can’t go far with those rules, Baron said, because a federal law prevents them from regulating self-funded health plans, which cover about 65% of enrollees.
“There would be major gaps in reporting,” Baron said.
A group of Democratic-led states argued this in a lawsuit last year, arguing to keep the requirements in place to prevent self-funded plans from denying preventive services, as they often did before the ACA.
Even when states can regulate what health plans cover, people still fall through the cracks. “I see denials all the time in cases where the treatment is clearly covered,” said Megan Glor, a health insurance attorney in Oregon.
Patients can appeal their insurers’ decisions, but it’s not easy. And if a patient’s appeal fails, litigation is usually the only option — but that’s a long, complicated and expensive process, Glor said. Perhaps the best outcome for a patient is for an insurer to cover what should have been covered in the first place.
When Engler called Kaiser Permanente about his vasectomy lawsuit, he said a representative told him the bill had been sent by mistake. Still, the insurer kept asking for money, he said. Engler filed and lost multiple appeals, eventually settling the lawsuit for $540.
Kristina Barker for KFF Health News
Engler’s vasectomy probably should have been free, Glor said. As a teacher, Engler is a public-sector employee, meaning his insurance would be subject to an Oregon law that requires free coverage for vasectomies.
Kaiser Permanente told KFF Health News that the state law doesn’t apply because of a federal rule for high-deductible health plans tied to health savings accounts, which requires patients to pay their co-pays until they reach their deductible.
After KFF Health News contacted Kaiser Permanente about Engler’s situation, Engler said the company promised to fully refund the $540 he paid to settle his case.
“While we administered the benefit appropriately, an employee who spoke to Mr. Engler incorrectly told him he did not have to share the costs,” said Debbie Karman, a spokeswoman for Kaiser Permanente.
Engler said he is pleased with the outcome, but he still doesn’t understand how Kaiser Permanente staff could have been confused about his insurance coverage.
He worries that others don’t have the resources he had to stand up for himself.
“It’s scary,” he said. “So many people have limited resources or their understanding of how to fight — or even who to fight.”
KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the main operational programs of KFF — the independent source for health policy research, polling and journalism.
