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Background.

Reproductive health care services do not fit neatly into many of the long-standing conventions of private health insurance in the United States, both because of the nature of the services themselves and because of the characteristics of the people needing them. As a result, these services pose a particular challenge to traditional forms of health insurance coverage.

While some reproductive health care services, such as prenatal care or abortion, are extremely time sensitive, they do not constitute "acute care" as generally construed for purposes of insurance. Similarly, while other reproductive health care services, such as contraception, may be necessary over an extended period of time, the individuals needing them do not have a "chronic" health condition in the classic sense of the term. In fact, the reproductive years are not a static period, but rather encompass several stages during which, as an individual's reproductive goals change, so do his or her health care needs. (1)

For example, during the years in which the typical young woman is sexually active before she wishes to have a child, she is likely to need contraceptive services to avoid unwanted pregnancy, as well as routine gynecological care that includes screening for sexually transmitted diseases (STDs) and cancers of the reproductive system, in order to protect her general reproductive health and ensure fertility in the future. During the years in which the typical woman is pregnant or trying to become pregnant, she should receive a preconception risk assessment and comprehensive maternity care, including prenatal, delivery and postnatal care. A woman confronting an unintended pregnancy may choose to have an abortion, while a woman or a man whose desired family size has been attained may seek a contraceptive sterilization. Both men and women may need services related to STDs or infertility.

Because of the multifaceted nature of an individual's reproductive health care needs, a comprehensive reproductive health care package must include the following core services:

* contraceptive services and supplies,

* abortion services,

* contraceptive sterilization,

* basic infertility services,

* screening for STDs and cancers of the reproductive system,

* medical services and risk assessment prior to pregnancy, and

* maternity care. (2)

Each service is important not only in its own right, but also in its critical relationship to the others. According to the U.S. Public Health Service: "Safe and healthful childbearing both contributes to, and is a result of, effective family planning. While miscarriage, stillbirth and infant mortality outcomes cannot be completely prevented by effective family planning, the frequency of occurrence can be reduced. Thus, preconception counseling and good gynecological, maternal and child health care are required for effective family planning. Reciprocally, effective family planning is a valuable aid to good maternal and child health because sufficient spacing of pregnancies helps to reduce the incidence of maternal morbidity, low birth weight and infant mortality." (3) Yet, insurance has not traditionally conceived of this set of interrelated, and interdependent, services -- including health care professional services, surgical services, drugs, medical devices and counseling and education services -- as a discr ete "reproductive health" package.

Moreover, the preventive nature of many key reproductive health care services--including contraceptive services, routine gynecological care and even prenatal care--may make them appear as not automatically fitting into the traditional health insurance framework that, in the United States at least, has covered curative care, such as surgical services, but not preventive care.

The characteristics of the population needing reproductive health care services also pose questions for insurance plans. Many of those needing services are minors and spouses, who may be in particular need of confidential care, but who are very likely to be insured indirectly as dependents on someone else's insurance policy. Among those with employment-related health insurance, 42% of women 18 to 44 have indirect coverage, compared with 31% of the overall population 18 to 44. (4) For dependents covered under a family member's policy, confidential access may be made difficult, if not impossible, when claims must be verified and submitted by the policyholder, who then receives the reimbursement from the insurer.

Further, many of these services involve some of the most private aspects of individuals' lives, and may require special sensitivity on the part of both health care providers and insurers. Some providers, whether institutions or individuals within these institutions, may object to providing certain aspects of reproductive health care, necessitating a careful balancing of these rights and those of individuals requiring care. As a result, adequately covering these services can raise some unusual issues for our current types of private insurance coverage, issues that may require particular attention when a health care reform plan is crafted.

The advantages of covering reproductive health services make resolving the difficulties involved worthwhile. For example, according to Richard Kiernan of Business and Health: "More effective contraceptive use may translate into fewer unintended pregnancies which in turn may result in lower pregnancy-related costs. Moreover, some birth control methods have non-contraceptive health benefits, which can help reduce the incidence of potentially serious diseases and their costly complications. Therefore, the advantages of ensuring that employees have access to a wide range of contraceptive methods become readily apparent....Contraception is an issue that is important to everyone concerned about employee wellbeing and about lowering health care costs." (5) Similarly, covering such services as prenatal care and screening for STDs and cancers of the reproductive system is cost-effective because it improves individual health and reduces the need for more expensive treatment once a medical condition becomes acute.

However cost-effective they may be for society, though, reproductive health care services can be expensive for an individual without health insurance coverage or even for an individual with insurance coverage that requires substantial out-of-pocket expenditures in the form of deductibles or other cost-sharing such as copayments (a requirement that the patient pay a flat, per-episode fee) or coinsurance (a requirement that the patient pay a percentage of the cost of care).

The total cost of maternity care, on average, was $4334 in 1989, according to the Health Insurance Association of America; the cost of a cesarean section was $7186. (6) The average cost of infertility diagnosis is likely to be between $500 and $2000, with conventional treatments doubling the expense. (7) Even in the case of outpatient abortion, which, when performed in the first trimester, costs an average of $300, out-of pocket costs can prove prohibitive for some women, particularly since unwanted pregnancy is a time-bound emergency. (8)

Contraception can also be an expensive proposition, although the cost varies depending on the contraceptive method that is used. (9) In 1993, the total cost of Norplant (effective for five years) likely exceeded $700 and the cost of an intrauterine device (IUD), effective for eight years, was about $500. A supply of oral contraceptives--the most commonly used contraceptive method--and the associated physical examination cost nearly $300 to avoid pregnancy for one year.

In general, most women in the United States rely on some form of health insurance to help them defray some of their medical expenses. According to a recent study conducted by the Women's Research and Education Institute, 67% of women of reproductive age rely on private, employment-related coverage, obtained through either their own employer or a family member's employer. (10)

While much is known about the coverage of reproductive health care services through public programs (publicly subsidized family planning clinics and Medicaid), (11) much less information is available on private-sector, employment-related insurance. It is imperative that current patterns of coverage and their shortcomings be known and understood if these shortcomings are to be avoided in whatever health care reform plan is ultimately enacted.

Notes and References

(1.) J.D. Forrest, "Timing of Reproductive Life Stages," Obstetrics and Gynecology, Vol. 82, No. 1,1993, pp. 105-111.

(2.) Based on resolution adopted by the Board of Directors, The Alan Guttmacher Institute, New York, March 1992.

(3.) U.S. Public Health Service, Department of Health and Human Services, Healthy People 2000: National Health Promotion and Disease Prevention Objectives (Conference Edition; Washington, D.C., 1990), p. 188.

(4.) "Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1993 Current Population Survey," Employee Benefit Research Institute Special Report and Issue Brief Number 145 (Employee Benefit Research Institute, Washington, D.C., 1994). Data concern only individuals aged 18--44; data for women aged 15-17, who are of childbearing age and extremely likely to have indirect coverage, are unavailable.

(5.) R. Kiernan in J. Burns, ed., Contraception--An Employers' Guide, a supplement to Business and Health, (Medical Economics Publishing, Montvale, N.J., 1993), p.2.

(6.) A. F. Minor, Research Bulletin: The Cost of Maternity Care and Childbirth in the United States, 1989 (Health Insurance Association of America, Washington, D.C., 1989).

(7.) American Fertility Society and RESOLVE, "Infertility and National Health Care Reform: A Briefing Paper" (Washington, D.C., 1993,) p.4.

(8.) S.K. Henshaw, "The Accessibility of Abortion Services in the United States," Family Planning Perspectives, Vol. 23, No.6, 1991, pp. 246--252.

(9.) J.D. Forrest and L. Kaeser, "Questions of Balance: Issues Emerging from the Introduction of the Hormonal Implant," Family Planning Perspectives Vol. 25, No.3, 1993, pp. 127--132.

(10.) Women's Research and Education Institute, Women's Health Insurance Costs and Experience, (Washington, D.C., 1994).

(11.) D. Daley and R.B. Cold, "Public Funding of Contraceptive, Sterilization and Abortion Services, Fiscal Year 1992," Family Planning Perspectives, Vol. 25, No. 6, 1993, pp. 244-251; S.K. Henshaw and A. Torres, "Family Planning Agencies: Services, Policies and Funding," Family Planning Perspectives, Vol. 26, No. 2, 1994, pp. 52-59.
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Title Annotation:of reproductive health care insurance survey
Publication:Uneven & Unequal: Insurance Coverage and Reproductive Health Services
Article Type:Topic Overview
Geographic Code:1USA
Date:Jan 1, 1995
Words:1580
Next Article:AGI Study of Private-Sector Health Insurance Coverage.
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