California wants to cut vasectomy and condom costs

SACRAMENTO, Calif. — California is trying to ease the pain of free vasectomy for millions of residents.

Federal law and state law require most health insurers to cover prescription contraceptives at no cost to the patient. But those provisions apply to only 18 FDA-approved birth control options for women, so anyone with testicles is out of luck.

California lawmakers are now considering a bill that would extend that requirement to male sterilization and non-prescription birth control, including condoms and contraceptive sponges. If the Contraceptive Equity Act of 2022 passes, state-regulated commercial insurance plans would not be allowed to impose out-of-pocket costs such as copays, coinsurance and deductibles on those methods of birth control.

“It’s quite groundbreaking in that way — it’s a whole new framework for thinking about contraception as something relevant to people of all genders,” said Liz McCammon Taylor, a senior attorney at the National Health Law Program, a group that advocates on these issues. Health rights of low-income people.

Vasectomy is an outpatient surgical procedure in which the patient’s sperm supply is cut off from his semen, the tubes that transport sperm from the testicles to the penis. Most men need to recover on the couch with an ice pack for a day or two, and a test a few months later to determine if the procedure has worked.

Since vasectomies are elective procedures and usually not urgent, price can be a deciding factor.

For Nathan Songon, the cost was the most stressful part of the process. For several years, the 31-year-old knew she didn’t want to have children biologically. Better to adopt a 4-year-old and skip the diaper stage, she thought. He was adopted as a baby by his stepfather and knew he didn’t need to be genetically related to his children to love them.

“My only concern was that I had no idea how much it was going to cost me because nobody told me,” said Songane, who lives in Mission Viejo, Orange County. If the procedure costs $1,000, as he expects, he won’t be able to afford it, he said.

One photo shows Nathan Songne posing for a selfie with a purple guitar
Nathan Songane, who builds guitars for a living, had a vasectomy on August 8. The procedure costs about $200 out of pocket.(Nathan Songne)

Song’s insurance, which he gets through his guitar assembly job, covered 70% of the Aug. 8 procedure, leaving his bill just under $200. “Cost influenced my decision, but because it was only $200, it made me feel a lot more relaxed about going ahead with the vasectomy,” she said.

According to Dr. Mary Samplasky, associate professor of urology at the USC Keck School of Medicine, the vasectomy business has two hot periods a year. First, he sees an uptick during the March Madness college basketball tournament, when men choose to recline on the couch watching hoops.

The end of the year is also busy, he said, because many patients can finally afford their annual insurance deductible and the procedure.

Patients negotiate an out-of-pocket cost of about 20% of his vasectomy consultation. “It’s obviously a nerve-wracking procedure,” Samplasky said. “And on top of that, if your copay is high, there’s even less reason to want to do it.”

In April, Jacob Ellert comparison shopped for a vasectomy near his home in Sacramento because his health plan didn’t cover the procedure. He had hoped to make a schedule with his regular urologist, he said, but that would have come with a $1,500 price tag.

Instead, he found a chain of vasectomy clinics where he could get the procedure for $850. Three months later, a test confirmed that the vasectomy was successful.

Elert has no regrets, but if price wasn’t a factor, he would have preferred to go to his regular urologist. “That’s the doctor I trust,” Ellert said. “But it was too expensive.”

In one photo, Jacob Ellert poses for a selfie.
Jacob Ellert wanted to have his vasectomy at his urologist’s office, but the $1,500 price tag was too high. Instead, he found a clinic that performed the procedure for $850.(Jacob Ellert)

In November, California voters will decide whether to lock abortion and contraception rights into the state constitution. But Proposition 1 doesn’t address issues like cost and coverage, said Amy Moy, spokeswoman for Essential Access Health, a group that administers Title X family planning programs in California.

“Constitutional amendments are long-term protections, and we’re still working to reduce barriers on a short-term and day-to-day level for Californians regardless of their gender,” she said.

SB 523 sailed through an early vote in the state Legislature, which faces a late August deadline to act on the bills. If the measure passes, it would go into effect in 2024 and California would join a handful of states that require their regulated plans to cover vasectomy or over-the-counter birth control entirely.

The California Association of Health Plans is still evaluating the measure, which could be amended in the final days of the legislative session. But the association generally opposes bills that require additional insurance benefits because they could lead to higher premiums, spokeswoman Mary Ellen Grant said.

SB 523 applies to more than 14 million Californians who work for the state, have a student health plan through a university, or have a state-regulated commercial health plan. They will also be eligible for free over-the-counter birth control — such as emergency contraception, condoms, spermicide and contraceptive sponges — in addition to vasectomy. The bill would not apply to millions of Californians whose health insurance plans are regulated by the federal government.

The specifics of how the benefit will work, including how much birth control frequency and amount insurers must cover and whether patients must pay upfront and pay later, will be hammered out after the measure is adopted. McCammon Taylor said it would be preferable to allow people to simply present their insurance card at a pharmacy counter and walk away with the birth control they need.

“We learned from the national trial of the Covid over-the-counter test that reimbursement is not the best model,” he said. “If people can’t pay for it out of pocket, they’re not going to get it.”

The California Health Benefits Review Program, which analyzes the law, estimates that about 14,200 people with state-regulated commercial insurance will get a vasectomy in California this year. Eliminating cost sharing would increase the number of vasectomies by 252 in the law’s first year, the program estimated.

This is a small increase. But that, plus other contraceptives included in the bill, especially a jump in condom use, could add up to a big reduction in unintended pregnancies. About 12,300 unplanned pregnancies could be avoided each year if the mandate went into effect, a reduction of more than 11%, according to the analysis.

This story was produced by KHN, which publishes California Healthline, the editorially independent service of the California Health Care Foundation.

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