March 01, 2012

Birth Control is a Medicare Issue

The battle over whether contraception is a basic benefit that must be included in any American health care plan has been called a lot of things. It’s been called a fight about religious liberty. It’s been called a fight about women’s health. Some have suggested it’s just an excuse for attacking the Affordable Care Act, Obama’s signature first-term achievement. No doubt it is all these things. But it is also, most dangerously, an attack on the concept of delineating “basic medical care.” And coming up with a single definition of basic care—and implicitly determining the essential insurance benefits that cover such care—is critical for the Medicare population, along with the rest of the country.

For universal coverage to work, either medical care must be provided directly by a centralized authority or medical care can be provided by the private sector, but government requires insurance coverage. The easiest way to achieve the latter is through single-payer insurance (Medicare-for-all); the US has rejected this option and chosen instead a decentralized approach: it is retaining its system of private health plans. It is not, contrary to widespread propaganda, offering government-run, top-down health care, or even a government-run health insurance program. If the system of multiple health insurance plans is to persist, AND coverage is to be truly universal, those plans must conform to national standards for what constitutes basic medical care. This is true however universality is achieved—whether it’s by a mandate or by a “health tax” that in turn gives a person a voucher to purchase insurance coverage.

The alternative to defining basic medical care is a system in which insurance companies can deny coverage for just about anything. They can institute the notorious pre-existing conditions exclusion. They can opt not to cover a variety of diagnoses, from prenatal care to alcoholism, to cancer, so as to avoid paying for conditions that are expensive under the guise of moral repugnance. This would make a mockery of “universal” coverage.

If we wish to retain the private health insurance system, and apparently this is what the US has decided on, insurance plans have to meet certain conditions. They have to be regulated. They can’t exclude coverage for pre-existing conditions. They have to provide a drug benefit. In short, they have to cover “standard medical care,” which means we must achieve a consensus about what standard medical care is.

Defining a standard is not such a terribly radical idea. The concept of basic benefits is well-established internationally. Developing countries have even endorsed the concept of “essential medicines,” or those drugs that make up basic medical care for a particular population.

Allowing a contraceptive exclusion and a host of other coverage limitations, ostensibly on moral grounds, undermines the very concept of basic benefits, the concept that is at the core of any universal coverage system. Medicare today is mandated by law to provide coverage for treatments that are “reasonable and necessary.” It is increasingly clear that this, too, involves defining what constitutes “essential treatment” or “basic benefits.” Medicare will become sustainable when it guarantees coverage for the basics and allows patients to decide about everything else. That’s the way it should be. Attacking the idea of basic benefits, which is what the contraceptive battle amounts to, is dangerous to the health of all of us.