The ACA Contraceptive Mandate Denies Male Responsibility in Family Planning

By Jessica Blakemore

Photo Source: Planned Parenthood (www.plannedparenthood.org)
Photo Source: Planned Parenthood

While much of the debate surrounding the Affordable Care Act’s (ACA) contraceptive mandate is focused on the fight over religious exceptions, little attention has been brought to the fact that the mandate does not go far enough to protect women’s reproductive autonomy. While the ACA recognized the importance of family planning by considering it preventative care and ensuring access to contraceptive options for all women (except those whose employers don’t believe in the right to reproductive self-determination, that is), it failed to recognize that men are active participants in reproduction.

By excluding vasectomies, condoms, and other male contraceptive services (including prescriptions for emergency contraceptives), the Department of Health and Human Services (DHHS) signaled that the role of men in regards to contraception is tangential at best. Further, HIV screening and counseling on HIV and other STIs is not required coverage for all adult males, only those deemed to be “high-risk.”[1]

The exclusion of men’s services from the contraceptive mandate harms women. It harms us by ensuring that women will continue to assume most of the burden of contraception and STI prevention, places all responsibility for unintended outcomes on women, and reinforces the nation’s current view of family planning as a “women’s issue.”

Women already assume most of the burden of contraception. Twenty-seven percent of reproductive-aged women rely on female sterilization for pregnancy prevention, compared to only 10 percent who rely on their partner’s vasectomy, though vasectomy is more effective than female sterilization at preventing pregnancy.[2] What’s more, women of color in the United States are far more likely to rely on tubal sterilization as a method of contraception than white women, and partners of black women and Hispanic women have particularly low rates of vasectomy.[3]

Female sterilization is considerably more invasive than vasectomy, and considerably more expensive. Vasectomy is one of the most cost-effective contraceptive methods available and is 20 times less likely to cause any post-operative complication. Vasectomy is safe, relatively low-cost, and extremely effective.[4]

The ACA’s recognition of contraceptive services as essential preventative care is a huge step toward ensuring that all women are free to make reproductive choices that that are appropriate for them. But the exclusion of coverage for male contraceptive services is a major oversight that denies the responsibility of men in reproductive outcomes and further solidifies the discriminatory and harmful idea that women should be totally responsible for family planning while paradoxically stigmatizing women, especially low-income and minority women, for demanding access to comprehensive reproductive healthcare.

Exclusion of coverage for male contraceptive services is discriminatory and increases the risk of further diminution of male involvement in contraception by increasing the comparative cost of vasectomy and providing an economic incentive for couples to chose female sterilization.[5]

The DHHS’s oversight is economically costly, inequitable and socially irresponsible. The contraceptive mandate should be amended to require coverage of male contraceptive options and STI counseling and preventative services to establish family planning as the responsibility of both men and women.


[1] Department of the Treasury, Department of Labor and DHHS, Certain preventive services under the Affordable Care Act, Federal Register, 2013, 78(127): http://www.gpo.gov/fdsys/pkg/FR-2013-07-02/pdf/2013-15866.pdf, accessed March 5, 2014.

[2] Brian T Nguyen, Grace Shih and David K Turok, ‘Putting the Man in Contraceptive Mandate’, Contraception, 89 (2014), 3–5 https://www.arhp.org/Publications-and-Resources/Contraception-Journal/January-2014.

[3] Sonya Borrero, Charity G. Moore, Li Qin, Eleanor B. Schwarz, Aletha Akers, Mitchell D. Creinin, Said A. Ibrahim J Gen Intern Med. 2010 February; 25(2): 122–128. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2837493/

[4] James Trussell and others, ‘Cost Effectiveness of Contraceptives in the United States’, Contraception, 79 (2009), 5–14.

[5] Nguyen, Shih and Turok, 2014.

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6 thoughts on “The ACA Contraceptive Mandate Denies Male Responsibility in Family Planning

  1. While I appreciate your argument, I find it to need significant reconsideration.

    The PPACA does not help nor does it hinder women’s reproductive autonomy. It has nothing to do with it—nor should it. The right to self-determination is not at issue here and does not belong in legislation meant to address issues of access and affordability in a broken health care system. The PPACA does not include contraception because it considers family planning preventive. It includes contraception, for women only, because it is preventive of serious diseases like endometrial and ovarian cancer, endometriosis, skin conditions, abnormal menstruation and related discomfort, and unnecessary hormonal shifts. Not because it prevents babies.

    PPACA does not provide coverage for female condoms as well as male condoms. Vasectomies and tubal ligations do not provide preventive benefits other than preventing the fertilization of an egg. Oral contraceptives do, for women. They do not for men because all of the conditions oral contraceptives prevent are unique to women. The only contraceptive for men, aside from a vasectomy and the ‘pulling out’ method, is a condom.

    Moreover, sexually transmitted infection screenings are only medically indicated for “high risk” patients. In medicine, someone is “high risk” if they are at a significant risk of contracting an infection. In other words, anyone who may have had a condom break or engaged in condomless sex or perhaps found out a partner had an infection afterwards would be considered high risk. This has been the standard of practice long before PPACA came into existence. To screen those not at high risk would be socially irresponsible because tests would be administered that are not indicated. You don’t get a thyroid function test just because it’s good to check, you get one if your doctor thinks it’s medically indicated. In a health care system that consumes nearly one-fifth of GDP, dolling out unnecessary tests is too costly to absorb.

    As an aside, I find it interesting that you chose the clinical term “vasectomy” for the male procedure but the more pejorative term “female sterilization” for tubal ligation. It’s also noteworthy that both procedures are, generally speaking, elective. Your comments about utilization and disparities are spot on, but are irrelevant to this argument.

    While I agree that women “assume most of the burden” (whatever that may be) of contraception, as a gay man, I disagree that women bare most of the burden of STI prevention. It seems to me that this is pure conjecture. You state that, “The ACA’s recognition of contraceptive services … is a huge step toward ensuring that all women are free to make reproductive choices that that [sic] are appropriate for them.” How are women limited, past and present, from making reproductive choices that are appropriate for them as a result of insurance coverage being unavailable for male condoms (the only feasible contraceptive available to men)?

    While I certainly appreciate women’s struggles through this issue, and consider myself an advocate of women’s health, this argument is fatally logically flawed. All of the adverse issues that women face in regard to reproductive justice are significant, but their roots are not in, or even close to, the PPACA or the perceived lack of coverage of men’s contraception.

  2. I appreciate your response, but I find that you have done little to refute my main point that not including male contraceptive services in the ACA mandate has the effect of continuing to place the burden of family planning on women and perpetuates the idea that male involvement in family planning is non-essential.

    You say that the ACA has nothing to do with women’s reproductive autonomy and that contraceptives are covered ONLY because of their use in the prevention of other conditions. Even if that is the case, the stated or perceived intent of the law cannot be held separately from the effects, intended or unintended, of the implementation of that law. If a law or mandate creates or perpetuates inequitable outcomes, than that law or mandate should be amended to ameliorate those externalities.

    The idea that family planning is not preventative care is an idea that is harmful to women’s health and economic well-being. Family planning enables women to avoid pregnancy when they do not want to be pregnant, plan for pregnancy when they do and foster their own health in the process. It has significant health and social benefits for society overall and the responsibility of men in regards to family planning should be recognized as essential.

    You write that vasectomies and tubal ligations do not provide preventative benefits other than preventing the fertilization of an egg, and for that reason vasectomy should not be included in the list of mandated covered procedures, because according to you, contraceptives that are covered only because they can be used in the prevention of other conditions. Your argument falls apart here because tubal ligation IS included in the contraceptive mandate. In fact, the mandate requires that women have access to tubal ligation, diaphragms, copper IUDs, and prescriptions for emergency contraceptives without co-pays. All of these are methods with no secondary preventative purpose. If these contraceptive services are included in the mandate, why shouldn’t vasectomy, a procedure that is extremely cost-effective and non-invasive, be included?

    Utilization rates and disparities between female sterilization-I used this term mainly because, when speaking with people about this issue it is much less common that they know the technical term “tubal ligation,” though in my experience most know what vasectomy means- and vasectomy are entirely essential to my argument. More than a quarter of insurance providers do not cover vasectomy at all. The fact that vasectomy isn’t covered by insurance incentivizes tubal ligations and perpetuates the disparity between men and women’s responsibility in regards to family planning and low-income women and women of color are disproportionately affected.

    Its telling that you write that male condoms are “the only feasible contraceptive available to men.” Vasectomy IS a feasible option and would be even more so if men could obtain the procedure at little to no cost, just as women can do with tubal ligation and other forms of birth control. Why is it more feasible for a woman to have an invasive procedure than for a man to have a non-invasive one that is proven to be more effective? To be clear, I am not saying that men should have vasectomies, only that it should be offered consistently as a viable family planning choice and should be covered in the same way that all other contraceptive procedures are covered under the mandate.

    Yes, women assume most of the burden of contraception. We are seen as being almost totally responsible for family planning, yet stigmatized for demanding access to viable family planning options and we bear the majority of the cost for unintended pregnancy outcomes. Yes, men do assume some financial burden in the form of child support, but in reality this pales in comparison to the economic and social cost women must pay for unintended pregnancies. The exclusion of male contraceptive methods from the mandate limits women’s reproductive choices by incentivizing procedures that may not be a particular women’s first or most appropriate choice.

    My point about coverage for STI screenings wasn’t that all people should be required to receive screenings and nowhere do I say that. My point is simply that STI and HIV counseling is mandated to be COMPLETELY covered for ALL women (regardless of risk category), yet insurance companies are only required to cover the costs of STI and HIV screening and counseling for “high risk” men. STI prevention is an important aspect of primary care, and if all women are able to receive no cost counseling and screening, shouldn’t all men have the same opportunity? There is a clear disparity here.

    You are correct in saying that the roots of the adverse issues faced by women in regards to reproductive justice are not in the ACA’s lack of coverage of men’s contraception. That wasn’t my point. My point was that the lack of coverage is indicative of our harmful cultural attitudes in regards to women, men, and family planning and that not including vasectomy and male contraceptive services perpetuates that imbalance.

  3. Ms. Blakemore and Mr. McGaughey seem well satisfied to spar away on intellectual distinctions, that equally show hate toward men. But I agree with Ms. Blakemore’s complaint about the ACA’s lack of coverage for men’s contraception, however we arrive at that agreement.

    I have no idea where each stands in their life experience. I will share mine with you.

    I am in my late fifties and have two children. My wife is younger than I. We have had all the children we want. This time in my life is correct for me to seek sterilization, but suddenly, because of the ACA and my employer’s response to it – to implement high deductible health insurance – I cannot afford the procedure as the full cost comes out of my pocket. Formerly, the procedure would cost only $100. Now, to receive the service in my network will cost $1500.

    I am saving for my children’s education and my wife’s retirement and every penny counts. We don’t make all that much money. The result is that I have foregone a vasectomy as unaffordable. My wife stays on hormones, which she does not like, but we can get for no cost share. And we certainly do not want to subject her to an invasive abdominal procedure like a tubal ligation. So we suffer under this law.

    I think the ACA should cover vasectomies with not cost share.

    I would like more discussion about correcting this flaw in the ACA. I would like it to be corrected soon enough to benefit my family.

    I also say to Ms. Blakemore and Mr. McGaughey that I despise your hate.

    • Mr. Wilson,

      There is no hate in either piece. This is a non sequitur. Even after Ms. Blakemore’s again logically flawed response, there is no hate. For your information, I’m a joint MPP/MBA student at Mills with a concentration in health policy. I have over 16 years of experience in the health care sector, the last 10 of which have been in research in biomedical ethics. Your and Ms. Blakemore’s notes say more about how much you do not understand about PPACA and health care generally than they do anything else.

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