I’ve addressed a couple issue regarding men and women the last couple of days, and a related issue appeared on my Twitter feed today. I had alluded to the issue of women and medical care, and several people posted about a feature of Obamacare that’s been getting some play: the fact that men will have to pay for insurance coverage of maternity. This mixes with the topics I’ve addressed in this space, particularly the physical differences between men and women that are bound to play out in the real world. Obviously everyone involved addressed the issue with an open mind and the subtlety that such a topic requires.
Just kidding. Mostly, people hated on Republicans for pointing out that this is stupid. Two articles in particular made the rounds. First, Lucia Graves (a woman!) of the National Journal:
[Obamacare] doesn’t allow for health plans to carve out certain things that might have allowed a health plan to price a product lower in the past—like allowing men to not pay for maternity care. That’s a policy known as gender rating. … Gender rating is prohibited under the Affordable Care Act.
…The argument for gender rating, in the days before the Affordable Care Act, had always been that women cost more to insure.
“When you get older, men cost more to insure than women.” .. Later in life, men are more likely to have a variety of conditions including heart attacks, lung cancer, and liver cancer. They’re also more likely to smoke, drink, and get in accidents, according to experts.
You’d expect insurers to charge men more as they got older, if they were in fact charging premiums based on actual usage. Graves gives us that answer, too:
insurers have historically charged younger women more than men in the individual market, even though those plans rarely covered maternity services. “That tends to reverse at older ages, when men have generally been charged more than women,” he said. “It’s reasonable to assume that insurers set those premiums based on the patterns of health care use that they saw.”
So, when allowed by law to do so, insurers charge each gender based on the expected health care usage. Seems fair.
In 2008 the average expenditure per person with an expense, including expenses covered by insurance and those paid out-of-pocket, was slightly higher for women ($5,635) than for men ($4,952), according to data from the Agency for Healthcare Research and Quality. But the difference in expenditures is largely attributable to childbirth.
Alright then, let’s address childbirth and the associated costs. Graves links to and endorses an error-riddled article by Jonathan Cohn at The New Republic. He makes four arguments to claim that men should be charged for maternity care under their insurance policies.
1. Healthy mothers and babies are good for you. Society has a legitimate, and very clear, financial stake in the health of pregnant women and young children. As Eduardo Porter noted recently in the New York Times, the U.S. has fallen behind peer countries when it comes to prenatal health. That has long-term consequences for prosperity and inequality, primarily because of the long-lasting effects it has on children as they develop. Obamacare’s requirement of maternity benefits won’t fix that problem, Porter notes, but it offers a chance to make the problem less severe. You can think of it as a public investment, just like roads, schools, and power lines—goods for which we all help pay, regardless of actual use.
I’m happy to concede that good pre-natal and neo-natal care has potential long-term benefits for the affected children – the literature on that is persuasive but not conclusive. I’m also generally willing to concede that certain public investments deserve government funding, though I draw these lines narrower than the mainstream. Charging insured men for maternity coverage, however, is a terrible way to fund such an investment. First, it’s regressive – all men are charged similar amounts, while investments funded from general taxes are funded more by the rich, who are taxed more heavily. Second, it hides the costs and the responsibilities of the program. Voters and taxpayers have no idea how much of any given premium goes to maternity, and can’t hold anyone accountable if they are dissatisfied with any of this program’s features. If the political goal is to publicly subsidize childbirth costs as a public investment, such costs should come out of general taxes, be a line item on the budget, and subject to voter scrutiny. As it is, they’re hidden away as premiums from private companies. This is a bad thing.
2. You may never bear children. But your mother did. …In this case, men who help pay for pre-natal and maternity costs are helping to shoulder the burden for costs that their parents bore, many years before.
This is pretty stupid. By paying for a stranger’s pregnancy I’m somehow repaying my mother? No. I buy my mother nice things to repay her for everything she’s done.
3. She supplies the womb, but you supply the sperm.
Yup. You should definitely contribute to the well-being of a woman with whom you intend to have a child. Anything else makes you an asshole. Don’t be an asshole. I’m not entirely sure why you bear responsibility for every other pregnant woman, too, though. What have you been up to, exactly?
Anyway, as I’ve said, if we are trying to subsidize a particular activity, we should do so explicitly through the budget.
4. So you ended up XY instead of XX. Get over yourself. Even conservatives generally stipulate that insurance should protect people from the financial consequences of random events. But they seem not to recognize that being born a woman is a random event. Sorry, dudes, you had no control over that. Allowing insurers to discriminate based on gender means penalizing half the population, just because those folks ended up with one type of chromosome instead of another.
Yeah, this is just very, very wrong. Yes, being born a woman is a random event. The proper role for insurance in that case is to insure BEFORE the event. Basically, if being a woman is costly (as it is claimed to be), you should insure against being a woman before you’re born. This is obviously impossible (though I bet there could be an insurance market for parents in this case), but it’s not something that can be addressed by insurance AFTER the random event. If certain houses in a neighborhood randomly burned down, insurance shouldn’t come in after the fact and equally spread costs over those who lost houses and those who didn’t. In any case, I’ve already made my point above how we should deal with the fact that one gender has potential costs associated with it that the other does not.
Of course, if you acknowledge point number 4, it has some implications for the rest of the health care debate. If we’re not going to make people pay higher premiums because of genes that determined their gender, then what about people born with genetic abnormalities? Or predisposition to diabetes, heart attack, or cancer? Pretty soon you end up arguing that it’s wrong to charge higher premiums to people who, through no fault of their own, happen to need more medical care—thereby conceding one of Obamacare’s core principles.
I concede nothing – nothing! While I’m generally sympathetic to those who suffer through no fault of their own – I’ve been lucky in that regard – any help we offer the unlucky should be explicit in the budget as I mentioned above, so that it can be properly evaluated to determine whether it fulfills its function in a cost-effective way. Second, most health conditions can be traced to genetics, even lifestyle ones – how do we know whether someone’s laziness and poor diet is a true choice and not influenced by genes that coded for poor willpower and a sweet tooth? Genes and nurture, neither of which you can choose, determine much of your adult health. Thus, to protect everyone from all random events, you must equalize all healthcare, and, as I’ve noted before, all wealth, and this must be repeated constantly. Now we’re back at communism, and I win.
It’s true that women beat most of the financial costs of pregnancy and childbirth. If we want to help them out, we should give them money when they’re pregnant.* We should not secretly charge insured men for something they won’t use.
*Assuming this is a behavior you want to subsidize. Many do not and think women who want to have children should first be able to afford them, with partner or not. It’s not the crazy wingnut position the two journals above would have you believe.