Sex mandates

Forbes , May 30, 1999

FROM FLORIDA TO ALASKA, state legislatures are debating whether to require private insurers to pay for contraceptives if they also cover other prescription drugs. Maryland enacted the first such mandate last year, and Georgia recently joined it. In all, 31 states will consider "pill bills" this session.

The birth control pill is nearly 40 years old. Why are politicians suddenly rushing to make insurers cover it? In a word—Viagra.

Only 40% of Viagra prescriptions are covered by insurance, compared with 70% of a typical drug of its age. But news stories about how insurers would cover Viagra led many people to think that male impotence gets better treatment than female contraception. State Senator Jackie Speier, sponsor of a California bill, says the pill "was discovered 39 years ago and we're still fighting to include it in prescription drug benefits. Viagra was discovered six months ago, and guess what? It's already there."

Both the pill and Viagra are about sex, of course, which makes them good for headline-hungry politicians. But the more important connection between the two drugs is more subtle.

Both raise questions about our definitions of health: Is a drug that changes a normal condition, such as fertility, medically necessary? What exactly is health, anyway—a natural norm, or a condition based on the individual's wishes? Such questions will become more pointed as medicine gives us more and more power to alter what nature hands out.

"Enhancement," which goes beyond merely curing disease, is the next great medical frontier.

These are slippery issues, illustrated well by Viagra. Is "erectile dysfunction" really a disease, or is it a normal consequence of aging?

Viagra may have been created to treat specific, disease-related conditions, such as the effects of prostate cancer or diabetes. But to some men, a truly "healthy" condition is what's normal for a 17-year-old. They want Viagra to restore their youth.

Similarly, to many women, normal fertility is undesirable and hence, as far as they're concerned, unhealthy. In truth, both Viagra and the pill are more about enhancing life than about curing disease.

Pill bill opponents sometimes make that point. Florida State Senator Jim Sebesta compares contraceptives to sunglasses—good to have, but not medically essential: "They're a matter of choice. They're not drugs. They're not medicine." He puts Viagra in the same category.

Others draw a different line. Testifying against the Connecticut bill, the interestingly named Reverend Joseph E. Looney called contraception "disgusting and demoralizing." Viagra, by contrast, "enhances a natural function."

The idea is that "natural functions" and medical conditions warrant insurance coverage, while the targets of other prescriptions, disgusting or otherwise, don't. That's a hard distinction to maintain. Indeed, many HMOs do cover birth control, which fits their traditional model of preventive, prepaid care.

Health simply is not a well-recognized, static standard. It changes with the available technologies, and with how individuals want to live.

Not every medical treatment is as obvious or imperative as setting a broken arm or defibrillating a heart. But just because something is a matter of choice doesn't mean it is any less valuable.

The problem with insurance mandates is that they insist on a one-size-fits-all definition—the worst possible approach in a rapidly changing medical environment. They make the health care system even less adaptable than it already is. Rather than let choice and competition sort things out in diverse ways, legislators are playing interest-group politics and engaging in emotional one-upsmanship: "What about my needs?"

These bills treat insurance not as a contract between consenting parties but as an entitlement for subsidizing "good" or "important" treatments. They thus subject personal values to collective, political decision making. They demand that we as a society determine a single standard of health. That may be good politics. But it's a bad precedent for the coming biological century.