The gender gap: health care's next frontier

Business & Health, Nov, 1998 by Jan Ziegler

Women's health is hot these days, but women continue to pay far more for their own care than their male counterparts do.

Soon after Viagra received market approval and insurance companies began weighing whether to cover a drug that would restore male sexual vigor, protest erupted. Wait a minute, the activists shouted: If men are more vigorous, aren't they going to be vigorous with their partners? And if those partners are women, won't they need protection from pregnancy? Who's paying for that? If an insurer pays for Viagra, isn't it discriminatory not to pay for contraception? Isn't this just another instance of gender bias?

Is there bias against women in the health care system? You bet - some, anyway. What The Segal Co. refers to in an August report as a "noticeable difference" in the way plans cover oral contraception and impotency treatment isn't the only instance of gender inequity, but it has rapidly become one of the most glaring and well-publicized examples. While the difference in insurers' response may be because impotence is considered a medical problem while pregnancy prevention is viewed as a "lifestyle choice," the report continues, both have to do with normal sexual function. And "disparities in coverage ... should cause plan sponsors some concern."

Just how much have women been given the short end of the stick? According to tallies compiled by the Alan Guttmacher Institute, which tracks reproductive health issues, and the Henry J. Kaiser Family Foundation, females of reproductive age with private, employer-based coverage spend 68 percent more out of pocket on health care than their male counterparts. And, although Viagra has only been on the market since April and many plans may reconsider, a new study finds insurers nearly three times as likely to exclude coverage of FDA-approved contraception than of the high-priced potency pill [ILLUSTRATION FOR CHART OMITTED].

Nobody has a handle on the cost of gender bias to the nation's health care delivery system, but if it affects care in a negative way it is certain to jack up the price. Says Brenda Craine, an American Medical Association spokeswoman, "If people aren't treated properly, there's obviously a societal cost."

The trend

The Viagra vs. contraception controversy is a continuation of the wake-up call that sounded in the 1980s, when it dawned on policy makers and scientists that medical research had slighted women for decades by leaving them out of clinical studies of heart disease and other conditions that afflict both genders. More recent studies - mostly those launched in the early '90s or later - have shown that when it comes to the heart and blood vessels, men and women are different. Which means diagnostic methods and treatments that work for male patients don't necessarily have the same outcomes in females.

Drug studies, too, have long been a source of inequity. Until recently, women were routinely excluded from studies of treatments for diseases that affected both sexes, often based on the rationale that drug testing could endanger their reproductive capacity and even harm a developing fetus. So clinical findings based on men's experiences were extrapolated to women. Since the early part of the decade, however, many research organizations have established policies requiring sufficient numbers of women to be included in such tests.

In 1994, the National Academy of Sciences' prestigious Institute of Medicine concluded that the bias in medical research had violated women's rights. A number of federal initiatives followed, such as the establishment of the Office of Research on Women's Health, an offshoot of the U.S. Public Health Service. Noting in a 1997 report, "The New Women's Movement," that private money often follows federal spending, Smith Barney reported that start-up funding for women's health care companies completing initial purchase offers in '96 topped $200 million.

While women's health remains hot, the issue of gender bias in health care is clouded by evidence suggesting men and women present differently and tend to interact with health professionals in different ways. Nonetheless, questions of gender equity are popping up throughout the delivery arena, with quality control, outcomes, treatment, diagnosis and communication all under scrutiny. Managed care, as well as our nation's legislature, is beginning to tackle the question of health care bias, with a growing recognition of the truth in the old saw about the goose and the gander.

Contraceptives: Mandated coverage?

Activists initially had little idea of how many health plans intended to cover Viagra. But they were ticked off to discover that many insurers were even considering it while coverage of contraceptives had languished for years. A study released this year by the Guttmacher Institute revealed that two-thirds of fee-for-service plans cover surgical abortion and nine in 10 cover sterilization, but only half pay for reversible contraception.

Managed care plans do only slightly better: Four in 10 bar coverage of contraceptives. And just four HMOs in 10 cover all five FDA-approved methods of reversible contraception: the Pill, the diaphragm, the injections (Depo-Provera), the implant (Norplant) and the IUD, the Guttmacher report said. An "antiquated" policy, according to spokeswoman Susan Tew. (The "morning-after" emergency contraception kit, which gained FDA approval in September, was not included in the study, but its impact is expected to be significant: Princeton University's Office of Population Research estimates that it will cut the nation's 300 million annual unplanned pregnancies in half.)