What’s next, birth control?
About a week ago, in a post responding to Bob Imbelli’s thread on the Stupak amendment, David Cloutier chastised progressives for exaggerating the implications of the amendment. He wrote, “When people say, ‘oh, what’s next, birth control, etc.’ this is just like Republicans claiming that this bill is a ‘government takeover’ and [that] Dems want government to run people’s lives and decide who lives and who dies. It’s just silly.”
This comment got me to wondering about the status of contraception and whether it would be covered under the health-care reform bill. As far as I can tell, the answer is no. I can’t help wondering why not. In the process of hunting around, I found some interesting facts.
In a study conducted in July and August of this year, the Guttmacher Institute surveyed 947 women aged 18-34 to explore how these women’s reproductive behaviors have been influenced by the recession. (This report can be found here; it’s under reports and the title is “A Real-Time Look at the Impact of the Recession on Women’s Family Planning and Pregnancy Decisions.”) Here are a few of its findings:
- Eight percent of women report that they sometimes did not use birth control in order to save money.
- Among women using the pill, 18% report inconsistent use as a means of saving money.
- Nearly one out of four women report having put off a gynecological or birth control visit to save money in the past year.
When states have tried to mandate insurance coverage for contraceptives, the Catholic Church has opposed these actions. For example,the Catholic Church fought to overturn New York’s “Women’s Health and Wellness Act,” which required employers who offer prescription drug plans to provide coverage of FDA-approved contraceptives for women, it doesn’t seem “silly” to ask whether there isn’t a slippery slope here. Will those who gushed about the Stupak amendment also gush about an amendment eliminating prescription coverage for contraception? (For NYTimes piece on the New York law, click here.)
Simply to clarify the discussion, it is not about birth “control”. That’s what obstetricians do.
What is meant is birth prevention.
Do any of the insurance gurus on this blog know what percentage of insurance policies offer coverage for contraceptive pills or device?My impression has always been that very few do, but perhaps that’s not the case. Of course, for many decades they didn’t really cover prescription drugs at all.
Peggy, This doesn’t exactly answer your question, but the Guttmacher brief on this lists the following information. This can be found under “Insurance Coverage for Contraceptives” at the link in the original post.
“BACKGROUND: While almost all insurance plans cover prescription drugs, many still do not provide coverage for the range of U.S. Food and Drug Administration(FDA)-approved prescription contraceptive drugs and devices. A number of states, however, require insurance policies that cover other prescription drugs to also cover all FDA-approved contraceptive drugs and devices, as well as related medical services. Some of these policies allow employers or insurers to refuse to cover contraceptives on religious or moral grounds. In addition, several states have limited mandates that apply to either specific types of insurers, such as health maintenance organizations (HMOs), or to coverage written for a segment of the insurance market. (Federal law requires insurance coverage of contraceptives for federal employees and their dependents; a few specific religious insurers are exempt from the requirements.)
HIGHLIGHTS:
␣ 27 states require insurers that cover prescription drugs in general to provide coverage of the full range of FDA-approved contraceptive drugs and devices; 16 of these states specifically require coverage of related outpatient services.
␣ 2 states exclude emergency contraception from the required coverage. ␣ 1 state excludes minor dependents from coverage.
␣ 20 states allow certain employers and insurers to refuse to comply with the mandate.
␣ 18 states exempt certain employers from including contraceptive coverage in their plans.
␣ 15 of these states permit religious employers to refuse to provide the coverage.
␣ 1 state allows any employer, religious or secular, to refuse the coverage.
␣ 3 states allow certain insurers to refuse to write plans that include contraceptive coverage.
␣ 1 state permits religious insurers to refuse to provide the coverage.
␣ 2 states allow any insurer to refuse to provide the coverage.
␣ 14 states require employees to be notified when their health plan does not cover contraceptives.
␣ 4 states attempt to provide access for employees when their employer refuses the coverage, generally
by allowing employees to purchase the coverage on their own, but at the group rate.
␣ 7 states have mandates that only apply to a segment of the insurance market.
␣ 5 states require HMOs to cover prescription contraceptives or “family planning services.”
␣ 2 states require insurers that provide prescription drug coverage for individuals or small employers
to offer contraceptive coverage.
Huh?
Federal and state governments give millions of dollars to Planned Parenthood and others to provide free or cheaper contraception to women esp. poor women.
JC: Can we have a few details on the ‘millions of dollars”: I don’t doubt you. But the larger issue raised by the Post: Will the new regulations that come with health-care reform (if it gets passed) limit what women have had before the reform.
Paul Lauritzen: Your comment doesn’t exacly answer the question: what percentage of women currently have coverage through their insurance policies? And what percentage don’t? And what in the health care legislation regulates those percentages?
Very interesting, Paul Lauritzen, to learn contraception is not covered in the health care bill.
Anything else, perhaps IVF?
Guttmacher says: “Public expenditures for family planning services totaled $1.85 billion in FY 2006.” http://www.guttmacher.org/media/nr/2009/02/23/index.html Most of this is Medicaid.
Obviously, not all of this money was spent on contraceptive devices per se, but on counseling, etc.
I will try to get some details but my sense from a few conversations is that the health care package (at least the House version) will provide lots of money (no clue of precise figures) for pregnancy prevention, much of which, or some of which, will be funneled through Planned Parenthood for contraceptive distributution.
Again, that is too vague.
Most insurance plans don’t cover ” birth-control pills.”
I think you’re also missing an important point here. If Obamacare passes, suddenly the debate over coverage for anything changes. The question suddenly becomes “Should taxpayers be forced to subsidize this?”
This would seem to be a scandalous denial of a woman’s reproductive rights by the American health care system until is it pointed out that people put off or pass by any medicines, procedures and surgeries, some of which are even life saving, for the very same reason. This is part of the general cost problem within the system.
So I would again argue that here we are not really in the realm of rights but in the realm of priorities. Contraception, abortion, and IVF fall into the class of things which are, simply put, elective. Until we can pay for those things that are not elective and get full utilization or compliance for those things, we should put the other things aside. There may come a time when we have a well functioning universal national health system where we can then discuss the merits of offering various kinds of elective coverages (and marshal moral arguments for and against) but we are certainly not there yet.
Birth control has been covered by most insurance policies. Abortion has too. There is no question about that.
While we are on this subject let us keep in mind the perspective of the hierarchy on this. During the Vietnam war there was little objection to the napalm that devastated Vietcong women and children. Many have said that the bishops would have objected if condoms were dropped over North Vietnam. Such a striking comparison should give everyone cause to put this whole issue in perspective. The empire says there should be prudence in torture and war but not in sex.
Bill: “Birth control has been covered by most insurance policies. Abortion has too. There is no question about that.” There is a question, Bill. Data?
Unagidon has put his finger on part of the issue; elective procedures. I still would like to see some statistics on actual insurance coversage for contraception.
“Elective” is the wrong word to apply to contraception, in the insurance analysis of the issue. In reality, most insurers have passed on covering contraception for the same reason they didn’t want to cover the cost of birth related care, diabetes supplies, vaccines, and other types of preventive care (which is really what contraception is). That is, insurers more or less believe either that people will use these things or not irrespective of the availability of coverage, and that any long term consequences of failing to do so will likely fall on other payers or the government (e.g., a poorly controlled diabetic is likely to need amputations or stroke related care after qualifying for Medicare).
Likewise, a woman who thinks birth control is “expensive” hasn’t priced disposable diapers and daycare lately, and will use contraception or become pregnant with or without insurance coverage.
This “excuse” has more or less worn thin at the state level, and there are more and more state mandates for the coverage of preventive care. In some states, for instance, if you offer Rx coverage, it must include contraception. It’s a patchwork, like everything else at the state level.
Well, this is water under the bridge, but the whole notion that “insurance” plans be required to cover small and routine expenses is silly. It contravenes the whole concept of “insurance,” which is to spread the risk of catastrophic incidents that few people could afford at any one time. That’s why it would be ridiculous to buy “car insurance” that pays for filling up your gas tank every week, thus adding a layer of bureaucracy to every gas tank fill-up.
Barbara said: ““Elective” is the wrong word to apply to contraception, in the insurance analysis of the issue. In reality, most insurers have passed on covering contraception for the same reason they didn’t want to cover the cost of birth related care, diabetes supplies, vaccines, and other types of preventive care (which is really what contraception is). That is, insurers more or less believe either that people will use these things or not irrespective of the availability of coverage, and that any long term consequences of failing to do so will likely fall on other payers or the government (e.g., a poorly controlled diabetic is likely to need amputations or stroke related care after qualifying for Medicare).”
Not really. Or, what you say can apply equally to brain surgery. States can create mandates for things, and sometimes the mandates are for things where society is lagging behind medicine, like mental health benefits. But other mandates are for elective procedures and the goal is to simply spread the cost (as opposed to spreading the risk). (Not sure where you see plans not covering vaccines, diabetic supplies, etc. Insurance companies know that preventative care is both cheap and cost effective.)
It is inevitable that when I make a financial argument classifying birth control and abortion as elective, someone retorts by saying that both of these are more cost effective than women having babies. And they are more cost effective than having babies. But I am saying that given that society has decided that having children is something that should be supported as a social value, it then moves out of the elective category. You can argue that birth control and other things should be moved out for their own good reasons, but right now they are, in fact elective in precisely the sense that election means. In the case of abortion, for example, it has always seemed to me that part of the “rape, incest, health of mother” argument is to move some possible cases of abortion out of the elective category. I think it is possible to make similar kinds of reclassification arguments for almost every other thing that’s elective. But the fact still remains that these things are elective in ways that many other things are not.
Although I am against abortion, I am not trying to sneak an anti-abortion thing under the wire here. However, no matter what someone’s position is on abortion, birth control, IVF or whatever, there is still the question of what should be funded FIRST in a national health care plan. What I object to is that this facet of the issue is often ignored, and the matter becomes another battlefield in the culture war. I won’t deny that this isn’t a major element of it, but this should not derail the main effort, which is at this point to fund what is really needed. And since our medical system is so primitive in this regard, I don’t see the question of what the basics should be as controversial as the larger question of which electives should be covered. Right now, under our current financing schemes, if something is covered, something else is likely not to be covered. In this scenario, where do the electives stand?
Peggy, you are right about the data. I wonder if there is greater coverage in the North East where in many places domestic partners are covered also. Also, you might be speaking from your experience which has been with mostly Catholic organizations. Therefore. Maybe unagidon can help on this matter. How much of it pertains to geography. Is it a blue state red state thing?
This whole discussion of “elective” raises the question of who decides? Yesterday’s announcement that changed recommendation on when and how often to have mammeograms produced this morning’s story (NYT) that doctors are going to stick to the old rules (or at least the doctors the Times interviewed).
Reports are that a panel(s) will make these calculations under the health-care reform rules, but what if Congress winds up making them. Yikes! It will be like a military establishment in every district. As the dialysis-for-everyone decision many years back demonstrates, Congress is the worst body to decide these matters.
Right now, under our current financing schemes, if something is covered, something else is likely not to be covered. In this scenario, where do the electives stand?
Unagidon,
It seems to me we’re not talking about “elective” as I understand it. Elective surgery is not necessarily medically unnecessary. Cataract surgery is considered elective, but I would be blind by now if I hadn’t had it, and I would be appalled if insurance didn’t cover cataract surgery. You are basically using “elective” to mean “what needn’t be covered by insurance so something else can be.” I think you are bringing your personal value system to trying to decide what should and shouldn’t be covered, and I think it is almost certainly impossible to do otherwise.
It seems to me you can’t claim abortion should not be covered in order that the money that would be spent on abortion be available for something else unless you can demonstrate that coverage of abortion makes the cost of insurance go up. Certainly if we get universal coverage without it including abortion, and all the women who would have had abortions go through with their pregnancies, there would be a whopping cost.
Unless you can actually demonstrate — with at least a few assumptions and some facts and figures — that covering abortion would increase the cost of insurance rather than keep it the same or lower it, you are just stating your own personal view that abortion should not be covered.
Pro-lifers want to see the number of abortions reduced. If there is universal coverage, and pro-lifers succeed in that, then costs are going to increase, since pregnancy and delivery and coverage of another person are certainly more expensive than abortion. The only way excluding abortion coverage from universal health insurance can save money is if women pay for abortion out of pocket.
I am not making a pro-choice argument here. I am just saying that you have not even begun to demonstrate an economic case for excluding abortion coverage.
Abortion coverage, birth control coverage etc. would make premiums higher with them than without them.
Regarding elective procedures, I am defining them relative to a definition of risk. There is a risk for disease spread over the entire population. Insurance as such (and this is what makes “insurance” different from “health benefits”) is that it simply distributes the risk of unforeseen incidents over a wider population. The trade off of possibly paying for something that you won’t use (since you don’t get a refund if you don’t end up going to the doctor all year) is offset by the fact that if you do need it, you may end up spending much less than you otherwise would. This is no different from car insurance. And this is what I mean by “non-elective”. Your cataracts would be non-elective in this sense.
Elective procedures are things that people may or may not choose to do. Falling into this is abortion, birth control, viagra, IVF, bariatric banding, over-the-counter pharmaceuticals, cosmetic surgery, hair implants, liposuction, etc. All of these are also handled by some sort of medical practitioner. All of them may be important to the individual consumer. But none of them constitutes “risk” in the same way that unforeseen medical problems constitute risk.
You would be entirely right to say that 1) you don’t accept my definition of risk, and that one can define pregnancy as a risk in the same way that one can define influenza as a risk and 2) one can define risk type subsets for almost all of these which further clouds the definition. THEN you can say that, in my case, I am simply asserting my definition of risk over yours and that I am therefore inserting a moral argument but hiding it behind a financial argument.
I don’t deny that all of these things depend on someone’s definition of risk. Further, definitions of risk change all of the time. However, I will still hold that 1) the list of things in the elective category above are at least controversial in the way that other things in the risk category are not and 2) if you argue that you don’t care if the thing you are talking about is “elective”, then I would argue that you have to admit ALL of the things in the elective category for the same reason. Society can argue about abortion, birth control or whatever as a risk item along with any pathology, but it doesn’t follow that these things should be privileged over all of the other things that would fit into an elective category. If you are arguing this, then I would put it to you that you are inserting your own moral position into the financial argument.
Again, I am not saying that we should not have this argument. I am only saying that what I am proposing is part of the total argument.
Regarding who should make these decisions (Margaret), that’s a tough one. We fight this all the time in the insurance business and we characterize this question as the “is medicine and art or a science”? discussion. If it is an art, then any physician should be able to do what they want. However, some “artists” will be better than others and the public would have a right to know what kind of artist they are going to. If medicine is a science, then it should be subject to the same evidence based evaluations as drugs are.
Better than ‘elective’ might be ‘medically indicated.’ One of the problems with medical ethics is that we often try to do it without defining its proper end(s)…and in so doing using important concepts like ‘health’ and ‘disease’ and ‘medicine.’ Admittedly, there are a small number of cases in the gray area…but, in general, we make important distinctions between procedures which are medically indicated and those which are not.
Some people reacted strongly to the possibility of Viagra being covered but not the birth control pill. But one could easily make the argument that the former is medicine treating a disease whereas the latter is (usually) not. Now if Viagra were covered and female fertility medicine were not, then this would be a different story and (in my view anyway) manifestly unjust.
But here’s the rub: abortion and contraception (though an obvious distinction should be made between their relative moral gravity) are (again, usually) not treating a disease. Where they are, then this is medicine, and they should be covered. (Stupak allows insurance to cover medically indicated abortions.) But when they are not medically indicated procedures, then they should not be covered…especially given our finite resources in the face of virtually infinite medical needs.
Unagidon, what has happened to the ‘risk’ of getting an STD since we started saturating our culture with contraception?
Charles, this is a false kind of logicl Labor and delivery are also not diseases. Vaccines are not treating a disease, and so on. Viagra does not treat disease — what Viagra treats may or may not even be due to a medical condition (unless you want to call aging a medical condition).
I happen to share the concern over the payment of first dollar expenses for routine needs, and don’t feel particularly strongly about mandated coverage of contraception, because it is an expensive benefit to cover, so long as there is a means for women of lower income to obtain it from subsidized agencies (Planned Parenthood or Student Health Services, e.g., where the government also forces pharmaceutical manufacturers to provide it a greatly reduced cost — this is a big difference that people don’t think about). Abortion, on the other hand, is not an expensive benefit to cover. It’s the very routineness of most drugs that makes them so expensive. Abortion, like labor and delivery, is not routine and is surgical in nature.
“Unagidon, what has happened to the ‘risk’ of getting an STD since we started saturating our culture with contraception?”
A fair enough question, but I would classify it with the general question of pathologies connected to underlying social problems. So to me, it would be the same sort of thing as saying “what has happened to the ‘risk’ of becoming obese since we started saturating our culture with corn syrup?” An important problem and one that should be addressed along with the medical coverage problem. But I am not sure that it can be addressed through the medical coverage problem.
Barbara said: “Charles, this is a false kind of logic Labor and delivery are also not diseases. Vaccines are not treating a disease, and so on.”
I disagree. If we were to talk in terms of pure financial efficacy, then we would not only be wanting to promote abortion, we would want to promote euthanasia or at least assisted suicide. And although you are correct that by my definition labor and delivery would also be “elective” (although I think I like Charles’ term “medically indicated” better) we have decided as a society to move labor and delivery out of that category and have done so explicitly. We may move other things out of that category as well; after all this is our medical system set up to meet our needs that is being discussed here. But I would argue that if we go this route, we would then have to open up the question of everything that does not fit the medical necessity definition and not just privilege some things.
Vaccines and preventative treatments fall under the category of increasing the efficacy of medically indicated treatments. Obviously it is better to avoid getting a disease altogether, both on a cost basis and on a risk basis.
The reason why pregnancy used to be excluded was that insurers said that parents chose to bring children into the world. I am not making this up, the issue was litigated in pregnancy discrimination cases — insurers and employers staked out a position on the matter. Likewise, using contraception bespeaks a choice not to get pregnant, and abortion bespeaks a choice not to stay pregnant. You can make the same arguments in favor of or against coverage on these grounds.
I don’t expect complete symmetry in deciding what should be covered, as there are different issues at stake, including relative cost and relative incidence of complications. But I reject the notion that these are different on the grounds of indelible logic.
I also reject that vaccines, for instance, increase the efficacy of medically indicated treatments. They do not. They are pure prevention, and in reality, they are not even medically beneficial, in many cases, for the individual with the insurance: I get the flu vaccine more to protect my young child or elderly relative than I do for my own health. The same is clearly true of chicken pox vaccines. Many people are treated so a few vulnerable people don’t face undue hardship. Indeed, many people might be better off without the vaccine, as they are more likely to get lifelong immunity.
Barbara, you are correct in your account of the insurance coverage of pregnancy, which is why I said that we (as a society) had explicitly moved it out of the category of “elective”. There also happen to be good risk reasons for this as well.
I’m not saying that there is an indelible logic. Certainly pregnancy is a case in point and there will be other things that I would argue are at the margins. For example, should cosmetic surgery for a large (but benign) birthmark on a child’s face be covered as medically necessary, since it might be keeping the child from socializing properly?
But I think there is as strong argument at the core for medical necessity (something is or is not) and the fact that there is grayness there as well doesn’t mean that the whole idea collapses and we can’t make the distinction.
When I said efficacy I was misleading. What I meant was that if polio is a medically necessary thing to treat, it is more effective to prevent it in the first place. Although I have heard that some vaccines may make a disease event more mild than it otherwise would have been, what I meant here is in the social treatment of disease prevention is part of the consideration.
Barbara, but the reason that labor and delivery are covered is with preventive respect to health concerns: it mitigates against the very real health problems that can arise in the mother and her child during the course of a delivery. In this sense, it is covered for much the same reason other preventive measures are covered and is thus medicine.
Abortion and other kinds of birth-control (once again, terminations and drugs done for specifically medically indicated reasons are and should be covered) are not related to the treatment or prevention of disease and thus should be not be covered in a medical insurance plan that is dealing with scarce resources.
Charles, these are post hoc, pretextual rationalizations. There are very real problems that can arise as a result of not covering abortion or contraception.
Barbara said: “Charles, these are post hoc, pretextual rationalizations. There are very real problems that can arise as a result of not covering abortion or contraception.”
This may be true. But this can be said of the other things (generally) that fall within the same classification. These problems are of course a legitimate part of the discussion of whether they should be covered or not. However, it has to be argued, rather than assumed, that there is something about abortion and contraception that makes them different from everything else that does not fit the definition of medical necessity.
You may also argue that the definition of “medical necessity” is arbitrary. I don’t think that it is designed to specifically exclude abortion or contraception. But I don’t think that we can get rid of the definition of medical necessity as such. There are going to be things that unambiguously fit that category, even under the law. Otherwise we would not be jailing people who let their children die of treatable illnesses because they would not pursue conventional treatment for them for religious reasons. Perhaps the top floors of the edifice built on this as we get into grayer and grayer areas should include the things I have put on the excluded list above. But each thing would have to have its own rationale.
Unagidon, I totally agree with you. Coverage reflects a lot of things, and frequently, interest group pressure as much as logic. What I don’t like is the insistence that there is a logical difference between coverage of pregnancy, on the one hand, and abortion and contraception, on the other, based on health related grounds, because I think that is manifestly not true. Just take abortion, for instance: women who can’t afford an abortion are more likely to have a less safe and more invasive abortion at a later date. A lot of abortions done in the second trimester are done for this reason alone.
There may be insurance, cost, social good or public health considerations, all of which can be legitimate.
There are many people — who I feel are full of baloney — who argue that everyday life has been “medicalized,” and people seek medical treatment for “ordinary aches and pains” that people used to put up with and seek antidepressants when they feel down in the dumps and antianxiety drugs when they are just coping with the everyday feelings that everybody else has. They claim that things like Restless Legs Syndrome — which I suffer from (and I do mean suffer) — are just invented diseases so that doctors have more things to bill for and drug companies have more drugs to sell.
Some argue that Post Traumatic Stress Syndrome isn’t a disease because of course you are going to be freaked out by seeing your friends dismembered in combat.
Of course, menopause is not a disease, and the suffering many women experience going through it is perfectly “natural,” so I suppose health insurance should not pay any of the cost of relieving the discomforts of menopause.
Also, there is plenty of medical care that does not deal with the prevention and treatment of disease. A broken arm or a burn or a gunshot wound is not a disease.
Ideas about how things should be are subject to change. For example, one of my aunts was naturally left-handed, but like many people of her generation was forced to learn to write with her right hand. Exactly how much harm came out of it I can’t say, but it was far from helpful.
Also, there are many procedures that are common that are dubious or harmful. Certain kinds of back surgery generally don’t help back pain, and CT scans of the spine are routinely done although they are not generally recommended because any anomaly that shows up is taken to be the cause of the problem, and it usually isn’t. (They are, in a way, much like false positives on more objective tests.)
A lot of argument over what is a disease (alcoholism?), what should be covered, and so on is going to be largely a matter of whose opinions win out and what people’s biases are. Some may be following the case of David Nutt, Britain’s chief drug adviser, who was fired for ranking the dangers of various drugs using scientific data as opposed to public prejudice. These things will not be easy to hash out, and there is going to have to be a lot of rigorous thinking to make sure good and fair decisions are made.
David, in case you were addressing me, I never said that something needed to treat or prevent a disease in order for it to count as medicine. (It is a sufficient but not necessary condition.) Obviously, treating a gunshot would concerns someone’s health in such a way that it counts as medicine. That you can point to procedures in the ‘gray zone’ (which I already admitted exist) does not make the distinction a meaningless one. And I’m at a loss to understand how anyone can argue that abortion and birth control (used to do something other than defend the health of a patient) could possibly be considered medicine.
Barbara, why would you insist on assigning motivations to someone rather than dealing with their arguments? The idea that abortion (and euthanasia, for that matter) it not medicine goes back to the founding of Western medicine and predates our current debates by about 2400 years:
http://www.pbs.org/wgbh/nova/doctors/oath_classical.html
That you can point to procedures in the ‘gray zone’ (which I already admitted exist) does not make the distinction a meaningless one.
Charles,
My main point is that it is difficult to come up with a set of criteria for what should and should not be considered legitimate, necessary medical care. And once you have the criteria, there is no guarantee that people won’t have good arguments for and against any given medical treatment. Personal beliefs and experiences are going to enter into it.
I am reminded of a fundamentalist Protestant argument I once saw about Jesus saying, “You are Peter, and upon this rock I will build my church.” One possible interpretation seriously put forward was was that it happened like this: Jesus said, “You [pointing to Peter] are Peter, and upon [pointing to himself] this rock I will build my church.” Of course, that isn’t a very good argument, but my point is that almost anything can be argued for or against.
The idea that abortion (and euthanasia, for that matter) it not medicine goes back to the founding of Western medicine and predates our current debates by about 2400 years
If you go to the doctor to have it done, it’s medical treatment (which doesn’t mean it’s good or that insurance should pay for it). All the major medical organizations back abortion rights. The majority of doctors can’t be wrong about what is medical treatment and what is not.
That the majority of physician back abortion rights doesn’t make abortion medicine anymore than that they fact that support voting rights makes voting medicine.
Surely, David, you’ll want to retract this statement once you think about the checkered history of what physicians used to think was medicine: “The majority of doctors can’t be wrong about what medical treatment is and what it is not.” Right?
The fact of the matter is that in today’s postmodern world the idea that medicine has any end or definition at all is questionable for many physicians today…medicine is increasingly more like Burger King, “Have it your way.” Medicine is whatever (legal) request the customer makes.
But if we actually think that medicine has any definition at all, we realize that it has something to do with health. And if we take such a definition seriously it just isn’t the case that ‘almost anything’ can be argued to be medicine. One might ‘go to the doctor’ to, say, get get a nose job or their penis enlarged…but the argument that this is medicine is just laughable because is has nothing to do with disease or health. Again, there are gray areas…but abortion and other kinds of birth control, because they have nothing to do with disease or health, cannot be medicine.
Charles,
I am perfectly happy with a definition of medical treatment as something along the lines of “what doctors do, and get paid for.”
Suppose a person’s face is badly burned, and when it heals they have ugly scars but can still see, hear, taste, and smell without any problems. I doubt that anyone would deny that cosmetic surgery to deal with the scarring was needed medical treatment. Suppose someone would be very attractive were it not for his hideously large, misshapen nose. If making someone look better (but not function better) because they were burned is medical treatment, why would it not be medical treatment to surgically fix the unfortunate person’s nose so he doesn’t frighten little children and get made fun of behind his back?
But a majority of doctors were paid for these procedures and called them medicine:
http://en.wikipedia.org/wiki/Nazi_human_experimentation
And this wasn’t just in Nazi Germany. Eugenic polities like forced sterilizations for the mentally disabled were favored by many physicians in many other places and times. Was that medicine?
I think cosmetic surgery for burns is a classic gray area case because you could argue that you are trying to fully heal a wound in a way that a nose job does not. But, once again, those gray areas don’t make the distinction meaningless.
Charles,
We’re talking about health care reform in the United States in the 21st century. I am happy to stick with my statement, “If you go to the doctor to have it done, it’s medical treatment (which doesn’t mean it’s good or that insurance should pay for it).” I’m not talking about Nazi doctors, or the ancient Greeks, or whatever. I am talking about what’s happening here and now. I think it is pointless to try to divide things that doctors do into medicine and not-medicine.
But David, where does that leave us? We don’t know what the costs of the national system would be. We have massive amounts of dollars flowing through the system now, and if we compare the United States to other developed countries with universal health benefits, it would seem that we should have more than enough of the national wealth in the system to provide health care for everyone. Yet the new proposals on the table would all add about $100 billion a year to this and we haven’t even come up with a definitive decision about what will and will not be covered.
It would be nice if anything that is done at a doctor’s office is covered. It would be nice if a whole host of alternative medicine were covered. Things like home births with midwives are generally safe and also cost effective. But the cost controls at the level of the providers that I have seen in all this legislation have been either primitive or non-existent. In the United States in the 21st century, we are going to have to figure out how to pay for things. And at the beginning, this is going to come down to what to include and what to exclude.
The question is highly politicized, of course. But we need some base to make the first cut. “Medically necessary” is not perfect in its unambiguity, But there is a range of things that everyone would agree are medically necessary and a range of things that people would agree are not medically necessary in the same way. There is a gray area between them. And here we will have to compromise.
What concerns me is that the health care debate is being turned into another battleground in the culture wars. In the context of setting up a basic health care system for the country, the question of whether abortion should be allowed and whether abortion should be paid for by the system are two different issues. One may argue that abortion is some kind of right and that therefore it falls into the same category as an emergency appendectomy. But I will hold that this isn’t an argument about abortions and appendectomys. It’s an argument about abortion and every other thing that might or might not be medically necessary against everything that unambiguously is medically necessary. We are talking about financing here. The time to consider adding abortion or the other things that I listed above will be after we have a functioning basic system.
I will expect pro-choice people to claim that if I make this kind of argument, I am really trying to sneak a pro-life position into the national legislation. I will counter that 1) do pro-choice really want the institution of national medical coverage to hinge on whether abortion is included or not and 2) are pro-choice ready to argue that abortion coverage is privileged over everything else that can be argued to not be medically necessary? Why abortion and not everything else?
David, presumably if medicine is ‘whatever a majority of doctors say it is’ then this would be a principle that you would apply in times and places beyond 2009 America, right? Presumably this would apply in 2010, too right? 2020? Then why not 1920? Would you have been willing to claim then that forced sterilization of mentally disabled persons was medicine because a majority of doctors said it was? Hopefully not. And the standard you would use would be outside of whatever physicians would use. Likely it would have some necessary connection to health: in which case abortion and contraception would (mostly) be out.
Charles: How is it that 2400 years of tradition should have more relevance to what constitutes modern medical care than the opinion of the majority of physicians currently practicing medicine? Both (assuming they are both true) are premised on consensus — which is David’s point — that consensus changes. For most of the western tradition, “mental illness” wasn’t considered illness at all. Does that mean what psychiatrists do doesn’t qualify as medical care because for eons the same symptoms were considered to be possession by the devil?
You also said that the reason that labor and delivery are covered “is with preventive respect to health concerns: it mitigates against the very real health problems that can arise in the mother and her child during the course of a delivery. In this sense, it is covered for much the same reason other preventive measures are covered and is thus medicine.”
And yet, the means to avoid those same “very real” health problems by avoiding pregnancy altogether or terminating one are not health related but elective, because . . . .”
By that logic, we would treat polio but not the polio vaccine. Or we would cover full-blown flu, but not the vaccine or tamiflu. Flu and polio, like pregnancy, are perfectly natural events in the course of human life.
Unagidon: And yet, miraculously, most of those countries that have universal health care provide contraception and abortion services. They see them as part of the “core services” that are essential to health and well-being and they provide them without breaking their budgets.
In light of the senate bill, perhaps we can rename this post, “What’s next, abortion?”
Barbara said: “And yet, miraculously, most of those countries that have universal health care provide contraception and abortion services. They see them as part of the “core services” that are essential to health and well-being and they provide them without breaking their budgets.”
Not a miracle. They all have effective cost controls. Since they have those, they can (and do) cover all sorts of things that we won’t be covering.
If you are looking for miracles, look at the US covering everyone else’s defense so that they in turn can allocate their wealth to taking care of social needs. It’s a miracle that we haven’t figured this out here.
Unagidon, I am sure you and I are on the same page when it comes to defense. As for cost control, all I can say is that the guns will not be aimed directly at cost centers until exclusion for people and services is not an option, and so long as fragmentation enables cost shifting, this will also be a delaying factor. You know all this.
Barbara, you missed the point of my posting the Hippocratic Oath. I was doing it to show you the claim that abortion is not medicine need not come from, as you argued, a desire to win our current culture war. It is a claim that is as old as Western medicine itself. Now, this of course doesn’t make it correct…as you point out…but that’s not responsive to the reason I brought it up.
Abortion and contraception can and should be covered if they are done for health reasons because then they are medicine…I already said that three different times. But the overwhelming majority of the 1.2 million abortions every year in the United States (along with the use of contraception) have nothing to do with health at all. Stupak allows abortions to be covered for medically indicated reasons. I would support contraception prescription for medically indicated reasons as well. But the argument that we should cover abortion and contraception merely for birth control misses the fact that we can’t afford to cover elective, non-medical procedures in a case of scare resources.
Barbara said: “Unagidon, I am sure you and I are on the same page when it comes to defense. As for cost control, all I can say is that the guns will not be aimed directly at cost centers until exclusion for people and services is not an option, and so long as fragmentation enables cost shifting, this will also be a delaying factor. You know all this.”
I agree that we both understand each other, although I am probably more sympathetic to the plight of women that find themselves with an unwanted pregnancy than you might think.
Regarding the delaying factor, what you say might be true except that you not only have to argue that abortion and contraception should not be excluded, but everything else that would excluded should be included. It’s not just that abortions are relatively cheap, so why not include them. Should we include Lasik surgeries (to think of something off the top of my head that’s probably about as expensive as a late term abortion). There is a list, and I think it’s a massive list given all of the lobbyists running around Congress these days, of things that people want included. So how would you exclude them and include what you want? Or would you include everything? Would we really be able to get this health system off the ground if we did that?
Mike M asked at 2:22 “Should taxpayers be forced to subsidize this?”
I ask, should taxpayers be forced to subsidize these:
1. Care for the obese who became so because of lifestyle and diet choices?
2. Care for people with emphysema because of years of smoking in spite of the Surgeon General’s warnings?
3. Care for many adult-onset diabetics whose affliction can most likely be attributed to diet and lifestyle choices?
4. Care for those injured in automobile, motorcycle and bicycle accidents directly attributable to inattentive driving, intoxication, drug abuse, etc.?
5. Care for people who attempt but fail at suicide?
6. Care for people who get STDs/HIV/AIDS because of practicing unprotected sexual activities?
We all have our pet sins that we don’t want covered by using OUR tax dollars.
I don’t want mine to go to pay for the Iraq and Afghanistan debacles, or military aid to Israel.
There is an obvious difference between not wanting to fund a particular war and being a principled pacifist who would oppose funding for all wars.
I don’t know about Mike M, but I wouldn’t want to fund any of the things that you listed. But, given the choice, I would fund those, and many others before I would fund abortion, IVF, etc.
This debate is somewhat disheartening, especially on a nominally Catholic blog. If polls are any indication, not funding abortions with federal dollars isn’t exactly a controversial position outside the halls of Congress or Planned Parenthood.
First, I obviously don’t think insurance should cover everything. I mean the cost of services that are covered.
But the larger question about what to include/exclude is hard to answer — one really interesting article I read asked us to step back and try to focus more resources, in general, on public health infrastructure and try to start moving away from what I can only call our reactive mode of practicing medicine. I agree with this, and I think that public health interventions at the individual level, including vaccines and contraception and smoking cessation, should be part of any benefit plan.
Also, a lot of cost drivers aren’t really a function of what is included, but how what is covered is delivered — and paid for.
One can also make a sincere argument that it is a complete waste of time to do research for things like finding the cure to lung cancer (e.g., more expensive drugs), when not smoking will eradicate about 80% of it over probably less than a 15 year period. 1/3 of all cancer, and I would venture, a comparable amount of all medical expenditures, are almost directly related to smoking. It’s not that I don’t have compassion for smokers, I do, but I don’t like being part of society-wide medical equivalent of Sisyphus. “Let’s intentionally make our job 10 times harder so we can prove our worth” is approximately what is going on now as it relates to smoking and cancer.
Paul’s question is a fair one, and I am glad that at least some data has been provided. According to the 2007 NYT article, contraceptive coverage is “commonly excluded” – yet according to Guttmacher (in Paul’s follow-up post), 27 states mandate that such coverage be included (with possible religious exemptions). Since I have to imagine that these 27 states have a disproportionate share of population, one would imagine that coverage is more common than not. Of course, for those of us (disproportionately represented on this blog!) who may work within Catholic organizations, the coverage is excluded.
My original comment assumed that, apart from lobbying against bills which would require Catholic organizations to provide coverage, Catholic legislators and lobby groups have made little public suggestion that laws should be passed prohibiting contraceptives, nor (to my knowledge) is there any equivalent to the Hyde Amendment on the issue of contraceptives. I would suspect/hope that Aquinas’ classic claim that civil law should not prohibit all vices, but only the most serious ones, would be followed here. It is fine and appropriate that we on this blog could have a debate about “medical necessity” and whether routine contraception use is “medical” or whether it involves a “pregnancy-as-disease” mentality, etc. But at the level of civil law in a pluralistic society, it would seem that the bishops have accepted the idea that contraception can be tolerated (though not endorsed or supported – hence, the desire for Catholic organizations not to be forced to provide it), but that the seriousness of abortion means that not only Catholic organizations but even the government itself should not be “supporting” it in any way.
I am very open to hearing that my presumption about the USCCB position is incorrect, but again, my original comment assumed that their approach to contraception and abortion in civil law made the traditional distinction about the seriousness of any given issue.