Like all wealthy countries, the United States has made a policy commitment to ensuring that everyone, regardless of income level, has access to enough food to sustain their health. One way we could make good on that commitment is by a system of compulsory food insurance: Everyone pays in, either via plans purchased on the individual market or through coverage employers are required to provide, and then you swipe your insurance card at the grocery store, and your insurance picks up the tab.
There are a bunch of obvious reasons this is not, in fact, the way we do things. The need to eat is not really a “risk” people need to “insure against.” Everyone needs to eat, and so the grocery bill is just a predictable, usually relatively stable, recurring expense. Second, while some bodies will need more food to sustain themselves than others—and there’s some minimum everyone’s going to have to spend on food to stay healthy—the cost, quality, and quantity of food people consume is also substantially a matter of individual choice and preference. You have foodies who devote substantial time, energy and money to culinary pleasures, and folks who keep a far more Spartan diet than they could afford.
So, of course, what we actually do is generally leave individuals with the responsibility of buying their own food, while providing subsidies of various sorts to the poor to ensure everyone is able to obtain some basic minimum, much as we do with necessities like housing or clothes. Many regard the current level of subsidy in the United States as inadequate, but that is no objection to the underlying structure of the arrangement, which seems to be widely accepted. Some expenses related to nutrition or diet are, of course, covered by insurance: Consultation with a doctor to identify medical conditions that may impose special dietary needs, or intravenous feeding for people who are either temporarily or persistently unable to consume ordinary food. But those cases provide no reason for covering routine food purchases on an insurance model.
The current debate over mandatory, no-copay contraceptive coverage under the Affordable Care Act is somewhat idiosyncratically focused on issues of religious conscience, and whether it is reasonable to compel employers with religious qualms about birth control (or certain forms of birth control) to directly underwrite it. That is surely a debate worth having on its own terms. But it strikes me as a bit odd that so little attention is given to the question of whether an insurance model really makes sense for contraception qua contraception—when it is not prescribed for some independent medical purpose.
There’s a dizzying array of condom brands and birth control pills, IUDs and long-term implants, surgical interventions, and so on, and people have an equally diverse array of reasons for preferring one option or another. Some people use one method or another of contraception pretty consistently throughout their adult lives, others only when they have chosen to be sexually active with a particular partner. While the costs of long-term birth control requiring surgery may be relatively high, the most popular forms typically involve regular, predictable expenditures within the means of the average person—costs which would doubtless be reduced if we sensibly allowed chemical birth control to be sold over the counter without prescription.
In short, birth control resembles food—surely a more vital health-related need—a whole lot more than it does the types of costly and unpredictable medical treatments that are the main reason for adopting an insurance model to pay for those types of healthcare. As a pure policy question, then, it seems more natural to adopt a similar model for contraception: Let everyone buy their own in accordance with their personal needs and preference, with subsidies for those below whatever income level we decide is appropriate.
The obvious reason we don’t do this, it seems to me, has very little do do with the policy merits and everything to do with politics. People who are opposed to mandatory contraceptive coverage are often simply opposed, on socially conservative or religious grounds, to contraception as such—or at any rate, to any government support for it. As with Social Security, the rationale for making coverage universal is a concern that a narrower means-tested program, though probably a better fit for the underlying policy goals, would not be politically viable over the long run. (“Programs for the poor,” as the saying goes, “tend to be poor programs.”) If conservatives were to accept the general desirability of guaranteeing broad access to contraception, it is hard to see any very compelling argument for using an insurance model to make good on that guarantee that would not apply at least as strongly to food, clothing, and housing—though I welcome any I may not have thought of in the comments.
15 responses so far ↓
1 TooManyJens // Dec 3, 2013 at 3:41 pm
“While the costs of long-term birth control requiring surgery may be relatively high, the most popular forms typically involve regular, predictable expenditures within the means of the average person”
This is circular, though. Those methods are popular in part because they’re easier to afford.
Long-acting methods are the most effective, and policy decisions should encourage their adoption by people who want to use them.
2 Julian Sanchez // Dec 3, 2013 at 3:48 pm
That would be an argument for mandating coverage of only those forms of contraception. Many people, of course, choose condoms or the pill even when cost is not a factor; if you want policy to encourage adoption of other methods, the idea should be to make them more attractive costwise.
3 Bo // Dec 3, 2013 at 10:43 pm
I think a lot of people might see the insurance model as making sense for contraception because they think buying contraception ultimately saves money by preventing pregnancies.
That is, the argument might go “Employers / insurance companies ought to pay for contraception; not doing so is shortsighted and foolish; contraception is cheaper than paying for prenatal care, a delivery, and any potential complications.”
I thought this (that paying for contraception is cheaper than paying for pregnancy) too, until a friend who works as an actuary explained that it’s not. In fact, it’s not even close – the probability contraceptives prevent an unplanned pregnancy is pretty good, but that they’ll prevent a planned one is pretty bad.
4 E.Z. // Dec 4, 2013 at 1:26 am
“The obvious reason we don’t do this, it seems to me, has very little do do with the policy merits and everything to do with politics.”
Which eventually leads to a pretty good argument against the current food stamps programs – the politicization of the personal decisions the recipients make (e.g., the debates over whether food stamps should be usable for buying soda or cigarettes).
I think what you’re making is an excellent argument against both the insurance model for health maintenance spending and, a few logical steps down the road, and excellent argument for a simple monetary safety net (something more like a minimum income, and a move away from instruments like food stamps).
5 alkali // Dec 4, 2013 at 11:56 pm
This would be true if you could buy the pill over the counter, which might be desirable, but as it is you need to go to a gynecologist familiar with your medical issues for a prescription, which ties that expense in with everything else that is ordinarily covered by medical insurance. If those who objected to contraception coverage only objected to paying for the pills it might be a simpler issue.
6 Tangentsreviews // Dec 5, 2013 at 4:56 pm
The difference between Food and Birth Control is this: Food is something we need in order to survive. Birth Control is a medication needed to improve quality-of-life. As it is medication, it is something all health insurance programs should cover. After all, they cover Viagra. Why not birth control pills?
7 emily // Dec 8, 2013 at 5:43 pm
” Let everyone buy their own in accordance with their personal needs and preference, with subsidies for those below whatever income level we decide is appropriate.”
I think I’m confused. How would this method counter the religious objections to birth control? Wouldn’t certain people be opposed to the poor spending their tax dollars on birth control like they are opposed to employers having to subsidize (in their view) birth control? Already the Hyde Amendment prevents Medicaid from paying for abortions, and people with objections to birth control generally believe (mistakenly) that the birth control pill is an abortifacient. This new idea seems like it will make a larger group angry, tax payers opposed to just employers.
8 emily // Dec 8, 2013 at 5:51 pm
disregard my last comment. I failed to understand your last paragraph. But upon reading this:
“If conservatives were to accept the general desirability of guaranteeing broad access to contraception”
please allow me to laugh heartily. Yes. I apologize. I didn’t realize you were playing such a hypothetical game.
So you’re basically asking, disregarding religious opinions, why we don’t get condom stamps like we get food stamps? From a public health perspective, it makes sense. The pill or the IUD or anything else you may get from a GYN may be more effective at preventing pregnancy, they are not effective at preventing STDs.
9 K. Chen // Dec 9, 2013 at 2:04 am
In lieu of something substantive – which seems to be likely well covered by others – I want to note that every time this past week I’ve brought up the website, I still do a double take and read “concentration camps” and then “concentration stamps.” Hopefully I am the only one.
10 Keith S // Dec 28, 2013 at 9:21 am
I don’t think food and contraceptives are comparable here. The main issue is that food is something you need to survive. Your rational self interest will force you into purchasing and consuming food. The fact of death is keeping you from suffering from starvation. However, there is no such mechanism for contraception; you can get pregnant and have a child even if you can’t support it.
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