California, Illinois, Maryland and Vermont have passed laws over the past two years requiring cost-free coverage of birth control options.
Like the Obamacare provision, the state laws cover one type of contraception per person -- including IUDs, oral contraception and tubal ligation. But all of the states, except California, also extended this benefit to include one other, far less popular family planning method: Vasectomy.
And with repeal of the federal law a real possibility, other states may soon follow suit.
New York Gov. Andrew Cuomo announced measures Saturday to ensure access to contraception at no cost and "medically-necessary abortion services" in the state regardless of what happens to Obamacare.
"These regulatory actions will help ensure that whatever happens at the federal level, women in our state will have cost-free access to reproductive health care and we hope these actions serve as a model for equality across the nation," Cuomo said in a written statement.
Vermont saw the law "as an insurance policy," according to Christopher Pearson
, a senator of that state and formerly vice chair of the state's house of representatives committee on health care.
"We were largely motivated by guaranteeing that the reproductive health benefits that came to the whole country by way of the Affordable Care Act were guaranteed to Vermonters should anything happen," said Pearson. "Little did we know how necessary it would be."
With the federal health effort focused on women's health, one premise of Vermont's discussion was "equalizing the playing field," said Pearson.
Though many people in his state had access to vasectomies or reversible contraceptives through their insurance plans, it appeared lower income women were often "relegated to birth control pills" due to costs.
The various family planning options currently available, including long acting reversible contraceptives and vasectomies, "shouldn't be based on your copay or your ability to pay," noted Pearson. Working on the law, he and his colleagues wanted an entire variety of "good options" to be "readily available for family planning."
The more Pearson and his team looked into it, the more that vasectomies fit into this philosophy.
Benefits of vasectomy
About 16% of men between the ages of 36 and 45 in the US have had a vasectomy, a surgical procedure for male sterilization, according to the Guttmacher Institute, a research and policy organization.
Not only is it virtually 100% effective, "it lasts for decades," said Mary Applegate
, associate dean, school of public health at University at Albany. "You occasionally hear about people getting pregnant after their partners' have had a vasectomy," said Applegate, but with the high number of procedures that have been performed, "sometimes things won't work."
Still, she said, "It's as effective as you've got."
Dr. Brian T. Nguyen, assistant professor in the department of clinical obstetrics and gynecology at the University of Southern California, said the procedure is "more effective than female sterilization, safer than female sterilization (and) less expensive by orders of magnitude."
Nguyen added that it's a relatively simple out-patient procedure that does not require anesthesia -- it can be done while a man is "wide awake," he said.
Pearson, himself, has had a vasectomy.
It was "not too big a deal in some ways," he said. "It was long understood in my family, between my wife and I, that we wanted to have two kids and after our second daughter was born, we carried that out... In fact, my insurance did cover it, so cost was not a factor in our family decision."
The estimated average cost was $713 in 2008, according to Elizabeth Nash, senior state issues manager at Guttmacher. Though, presumably, that price tag is higher now. She said costs today would depend on whether a person's "health plan covers vasectomy without cost-sharing, or if the person only had to pay the co-payment for an office visit or if the person had to meet a deductible and so on."
However you calculate the numbers, the procedure is not equally available to all men, according to Nguyen.
"It's easy for men who live in metropolitan areas who have comprehensive insurance plans to get a vasectomy, but this doesn't apply to men who live in rural areas, men who aren't insured or men who are under-insured," said Nguyen. "Quite frankly, if a vasectomy provider thinks that his/her services aren't going to be reimbursed in a certain region, he/she isn't likely to set up shop there and so there are wide swaths of men for whom vasectomy is inaccessible."
Another issue: vasectomy has become a procedure only urologists provide, said Nguyen. "Decades ago, vasectomy was being performed by primary care providers, but we don't see this anymore."
Last year, Nguyen published a study in the medical journal, Contraception
, that explored whether it might be possible to broaden the network of doctors who can provide vasectomies.
Surveying members of the Family Planning Fellowship network, comprising of physicians who specialize in the provision of contraception in the United States, he discovered a lot of interest among Ob-Gyns and family doctors to provide vasectomy.
"I think the next step is to create opportunities to train them and to ensure that physicians who want to provide the technique can be reimbursed," said Nguyen.
Public health, economic sense
Historically, family planning has been covered in this country for a variety of reasons, according to Applegate. Primarily, it has been seen as a very cost-effective method of providing the public health benefit of fewer unintended pregnancies and fewer preterm babies.
"If you have a huge Medicaid budget one of the most effective ways of keeping that Medicaid budget in control is preventing unintended births," said Applegate. "So the cost of the most expensive form of birth control -- like an IUD or a vasectomy -- is way less than even the cost of a healthy pregnancy and birth."
Providing both a public health and an economic benefit, family planning was, years ago, "very much a bipartisan issue," said Applegate. On both sides of the aisle, it was commonly considered a "why wouldn't we cover this? kind of issue," she said.
In fact, the Title X of the Public Health Service Act
, which supports family planning, was signed into law by former President Richard Nixon in 1970.
"Most people think, 'What -- wasn't he a Republican?" said Applegate. "In recent years, it's become much more embroiled in social policy."
As Applegate sees it, the reason why individual states may be including vasectomy in their contraceptive coverage today is simply to maximize availability of it and positively impact public health.
Considering why states are only now beginning to require coverage of the procedure, Nguyen pointed out that reproductive health care policy has long focused only on women.
"The real question is why this hadn't been happening years ago," said Nguyen. "Right now men only have condoms and vasectomies when it comes to birth control, whereas women have a lot of options so there's a big gap to be filled there."
For Nguyen, reproductive health care has always been an issue for men, women, and couples.
"It's a great option for families and its fairly popular, so we wanted to make sure it was widely available for Vermont families," said Pearson. "The bottom line is it's a one time thing that takes very little time and effort and it's extremely effective."