Yesterday, it was my pleasure to offer an "ACA Update" to several hundred advance practice nurses (many of them certified nurse midwives) at their annual Women's Health Care Symposium. Just as you might expect, I discussed access to contraceptives through preventive services for women under minimum essential benefits (the so-called "contraceptive mandate"). What you might not expect is that I also discussed access to contraceptives and reproductive services for men under the ACA. Specifically, there has been considerable confusion about whether the ACA extends minimum essential benefits coverage for men to include vasectomies.
Vasectomies are not considered minimum essential coverage for men under the ACA. If this lack of mutuality troubles you, remember that men are not a protected class for equal protection purposes. Although the equal protection clause of the 14th Amendment is often popularly portrayed as requiring the government to treat all citizens equally, non-protected groups, such as men, have a much harder time making their case. Not that I have found any litigation brought by men in this matter. Indeed, vasectomies are considered underutilized by those who scrutinize reproductive health. You should also know that, before the ACA, of health plans that offered surgical sterilization as a covered event, a full 10 percent did not offer it to men as well as women.
Why talk about vasectomies at a women's health care event? One reason to do so is because vasectomies, in general, are both safer and cheaper than surgical sterilization (think tubal ligation, etc.) for women. A second reason is to think about how focusing ACA reproductive services attention on women highlights the conflict inherent in the modern clinical encounter's emphasis on treating only the patient before you when, in fact, the reproductive fate of a monogamous heterosexual couple — for example — may require examining the reproductive health options of both members of the couple. A third reason is to get my listeners thinking about how the way we structure the allocation of reproductive health services both reflects and re-enforces our own cultural views on whose responsibility or concern limiting fertility really is.