David Engler had been pretty sure he didn't want children. Then a frustrating school day two years ago helped seal the deal for the 43-year-old substitute teacher.
“It was wild. I had to call the office seven times to get the kids out,” she 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 her the procedure would be free because it was a form of birth control, she said. But after undergoing vasectomy last winter, he received a bill for $1,080.
“I felt defeated, cheated and frustrated,” said Engler, who lives in Portland, Ore.
Engler's experience highlights how a labyrinthine patchwork of insurance coverage rules attention to reproductive health it 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 the consumer — does not require vasectomies to be covered.
And this perplexity surrounding coverage can be more complicated.
An ongoing federal The lawsuit aims to overturn the ACAPreventive care coverage requirements for private insurers. If the case eliminates 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 pre-Obamacare, said Zachary Baron, a researcher at health policies at Georgetown. law
It would create an environment “where insurers and employers choose 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.”
Studies have shown that requirements to cover preventive care have reduced consumers' out-of-pocket costs and increased their use of short and long term contraceptive methods.
The role of defining which contraceptive services should be covered rests with the Health Resources and Services Administration, or HRSA. Two other groups, the US Preventive Services Task Force, or USPSTF, and the Advisory Committee on Immunization Practices, or ACIP, make recommendations about other types of care that the ACA requires insurers to cover.
The plaintiffs in the lawsuit, a group of Christian-owned individuals and businesses, argue that the members of these three panels have not been properly appointed by Congress. They also tell the recommendations of the insurance plans to cover HIV prevention medication violate their religious rights.
On June 21, the U.S. Court of Appeals for the 5th Circuit issued what it called a “mixed bag” opinion on the case. He said one group, the USPSTF, had not been properly appointed and therefore its recommendations made after the ACA was signed were unconstitutional. The plaintiffs had asked for a national ruling, but the court said only the plaintiffs' organizations could be exempt from its recommendations.
The court then remanded the plaintiffs' challenges to the recommendations made by HRSA and ACIP, including those on contraception, 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 a ruling striking down the entire law that the US Supreme Court struck down later.
“O'Connor is a judge notoriously hostile to the Affordable Care Act,” said Gretchen Borchelt, vice president for reproductive rights and health at the National Women's Law Center. “He's someone who's willing to impose remedies where care is accessed far from everyone in the country based on what's going on in a situation.”
A victory for the plaintiffs, he worried, could create confusion about what kind of contraception is covered and how much it costs, ultimately leading to more unintended pregnancies, all at a time when women have less access to the abortion
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 briefs warning of the potential disruptions a decision for the plaintiffs.
Jay Carson, an attorney with the Buckeye Institute, a conservative think tank, said he is pleased with the court's decision. 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 should be covered, Carson said. “We've come a long way from Congress making the laws, and instead we're relying on Congress to just empower some agency to do the heavy lifting.”
What power agencies have is likely to be reduced in the wake of a June 28 U.S. Supreme Court decision that overturned decades of precedent that dictated that courts should defer to federal agencies when it deals with regulatory or scientific decisions.
“Courts will be better able to scrutinize experts,” said Richard Hughes, a health regulatory attorney at the firm Epstein, Becker and Green. “It's a change of atmosphere: we're moving in the direction of reducing the administrative state.”
Eliminating federal coverage requirements for contraception would leave it up to states to determine what services health insurance plans should provide.
Fourteen states and Washington, DC, currently protect the right to contraception. But states can only go so far with those rules, Baron said, because a federal statute prevents them from regulating self-funded health plans, which cover about 65 percent of workers.
“It would leave significant gaps in coverage,” Baron said.
A group of states led by Democrats made that argument in a court filing last year, arguing that the mandates should remain to deter self-funded plans from declining to offer preventive services, as they often did before the ACA.
Even when states can regulate which 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 the decisions of their insurers, but this is not easy. And if a patient's appeals fail, litigation is generally the only option, but that's a long, complicated and expensive process, Glor said. Probably the best outcome for a patient is an insurer that covers what should have been covered in the first place.
When Engler called Kaiser Permanente about her vasectomy charge, she said a representative told her the bill had been sent in error. Still, he said, the insurer kept asking for money. Engler filed and lost several appeals and eventually settled the charge 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, which means his insurance would be subject to an Oregon law mandating no-cost coverage for vasectomies.
Kaiser Permanente told KFF Health News that the state law does not apply because of a federal rule for high-deductible health plans combined with health savings accounts. This rule requires patients to cover out-of-pocket costs until their deductible is met.
However, after KFF Health News contacted Kaiser Permanente about Engler's situation, she said the company promised to issue a full refund of the $540 she had paid to settle her case.
“Although we administered the benefit correctly, an employee who spoke with Mr. Engler incorrectly told him that he should not share the cost,” said Debbie Karman, spokeswoman for Kaiser Permanente.
Engler said he's happy with the outcome, though he's still not sure how Kaiser Permanente staff got confused about his insurance coverage.
He worries that others don't have the means he had to defend themselves.
“It's scary,” he said. “So many people are limited in their 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 core operating programs of KFF — the independent source of health policy research, polling and journalism.
