Under Obamacare, birth control pills are free. Why aren’t vasectomies?

In early May, after the Supreme Court draft opinion to overturn Roe v. Wade leaked, Google searches for vasectomies spiked — and then spiked again in late June when the final decision was handed down on June 24.

Bobby Najari, a urologist and assistant professor at NYU Langone Health, says some of that spike translated into a modest uptick in vasectomy consultations. “It came up in a consultation about vasectomy just today with a patient saying that [the Supreme Court decision] just highlighted the burden that is placed on women when it comes to reproductive health.”

Despite the sudden interest in the term, chances are it won’t lead to a wave of vasectomies. According to 2019 CDC data, women undergo tubal ligation, the female sterilization method colloquially known as getting one’s tubes tied, at more than three times the rate that men get vasectomies, which involves minor surgery to prevent sperm from moving out of the testes.

The sterilization gap persists in the face of the clear medical facts that vasectomies are slightly safer, less invasive, and four times as cost-effective as tubal ligation. (Vasectomies are also the most cost-effective contraceptive over time.)

Tim Ryan Williams/Vox

Much of the sterilization gap can be explained by the simple fact that the burden to prevent pregnancy in the US — like the burden of managing childbirth and reproduction more generally — disproportionately falls on people who can become pregnant.

One example: Mara Gandal-Powers of the National Women’s Law Center notes that, prior to birth, many health providers ask in advance whether the child will be the person’s last, and if so, whether they would like to have their tubes tied. “I think that partially contributes to [the gap] … but I also think there’s a reason why providers are asking that and not asking do you or your partner want to have a sterilization after this last child?”

There’s no easy way to shift at least some of the contraceptive burden onto men. There will be moments, like the overturning of Roe v. Wade, that prompt introspection and, for some, action. And forthcoming technologies, like male birth control pills and injections, could provide more flexible contraception options for men.

But simply making vasectomies more accessible and less expensive could shift some of the burden soon, at the moment when it is most needed: The overturning of Roe v. Wade will severely restrict or practically eliminate abortion access in over 20 states, which will disproportionately affect low-income people and people of color.

With Republicans gearing up to further restrict access to abortion and potentially contraception, and Democrats’ options to fight back limited, modest measures like increasing access to vasectomy care could be a previously underutilized route for change and serve to level some of the playing field of birth control.

Making the snip accessible

The Affordable Care Act, or Obamacare, requires insurance providers to fully cover 18 forms of contraception for women, including sterilization. That means that if you want to get an IUD copper ring or get on the pill, you shouldn’t have to pay a single cent, though there are notable exceptions. Some health plans have onerous restrictions and employers that object to contraception on religious grounds are exempt from Obamacare’s contraception mandate due to the Supreme Court’s 2014 ruling in Burwell v. Hobby Lobby.

If you want to get a vasectomy, you’ll probably have to pay at least some of it out of pocket. Obamacare doesn’t require insurers to fully cover the procedure and health insurance plans vary on how much of the procedure they’ll pay for. Plus, millions of Americans still lack any kind of health insurance.

Congress could help to close the sterilization gap. The Affordable Care Act required insurers to cover a few categories of preventive services without cost-sharing, including women’s health care; Congress could pass a law requiring the ACA to cover contraception for all genders, or expand the law’s requirements to include preventive services for men. But Liz McCaman Taylor of the National Health Law Program says a regulatory approach makes more sense, since panels — composed of doctors and health experts and mostly commissioned by the Department of Health and Human Services — already actively determine which preventive services Obamacare covers.

One of those panels is the Women’s Preventive Services Initiative. While some reproductive health advocacy and research groups, including Taylor’s, have requested the panel add vasectomy to its set of recommendations, the procedure didn’t make the cut in its latest update, which was finalized in late 2021.

The reasoning is that even though women do stand to benefit from their partners getting a vasectomy, vasectomies aren’t performed on or used by women, so it isn’t currently considered a preventive service for women. But that doesn’t mean the panel’s experts couldn’t change their minds; coverage for condoms was included in the panel’s late 2021 update.

Another panel that recommends preventive services under Obamacare — the US Preventive Services Task Force, which recommends a wide array of preventive services for people of all genders — could also get the job done.

But an obstacle to expanding coverage is the paucity of research around vasectomies, said Taylor. “I think most if not all of the contraceptive research is dominated by women’s methods, so that doesn’t leave advocates a lot to go to the [panels] with. The fear is if you don’t go to the [panel] with strong research, they’re going to come out with a D [not recommended] or I [inconclusive] rating.”

Some progress has been made at the state level to expand vasectomy access. Around 20 states cover part of the cost of vasectomy care in their Medicaid expansion plans, and seven states have passed laws that require their state-regulated health care plans to fully cover contraceptive care for people of all genders, which includes vasectomy care.

But in 2018, the IRS issued new guidance that hobbled those states, saying that allowing individuals with high-deductible health plans (HDHPs) — in 2017, that was over 40 percent of insured Americans — to receive vasectomy care at no cost before meeting their deductible would mean they’re no longer HDHPs. People with those plans would no longer be eligible for tax-free health savings accounts.

The seven states had to either put the vasectomy component of their laws on hold or amend them to comply with the IRS guidance. The National Health Law Program wants to see the IRS change its guidance, but it’s not a top priority given the more pressing threats to contraception access and reproductive rights resulting from the overturning of Roe.

Changing roles in family planning

More than the thicket of regulations or the obstinance of insurance companies, however, reproductive rights experts say the biggest barrier to closing the sterilization gap is that US culture puts the onus on women to be responsible for birth control. And one symptom of that is the fact that research and development to expand options for men, like a pill or injection, has been anemic.

“It’s a real shame, and especially right now when we are starting to see calls for men to step up and generally people who can impregnate other people to take responsibility,” said Gandal-Powers. “I think there aren’t a lot of ways for them to actually prevent pregnancy.”

“As a man, I’ve only ever been told condoms or vasectomies are your two options, and condoms suck,” Rob Venturo, a 33-year-old supply chain consultant from Connecticut, told me outside the Supreme Court on the day Roe v. Wade was overturned. (Employed properly and regularly, condoms are an effective birth control method, and unlike vasectomies, also provide protection against sexually transmitted diseases, but the perceived reduction in pleasure has been a stubborn obstacle to their use.)

Venturo said he and an ex had discussed his getting a vasectomy, but the semi-permanent nature of the procedure — vasectomies can be reversed, though success isn’t assured — didn’t feel right, as he said there’s a chance, albeit slim, that he may want to have children someday. “We thought about it, but vasectomies are more permanent, right? An IUD is something that’s temporary, so that was why we went with that route.”

There have been efforts underway for decades to create male birth control pills, and more recently, an injection, but none have come to market. Adam Sonfield, a health policy consultant whose 2015 report on vasectomy access inspired this article, said there’s a “running joke that the male birth control pill is always five years down the road, no matter what year [it is].”

An effective, commercially available male birth control pill would probably do more to shift the burden of birth control than just about anything else. But until one is available, a vasectomy will usually make more sense than tubal ligation for couples and individuals who know they don’t want more children, or no children, because they are safer and less invasive than tubal ligation.

Ad blitzes could move the needle too. In the 1990s, a TV and radio commercial campaign promoting vasectomies in three major Brazilian cities temporarily increased vasectomy rates there between 59 and 108 percent.

Dr. Najari, the urologist in New York City, said he has seen the potential beginnings of a culture shift in recent years among patients who come in for vasectomy consultations. “I do remember the sentiment years ago being more ‘I’m here because my wife told me to be here’ — essentially she got sick of being on contraception or for medical reasons she’s not able to be on contraception,” Najari said.

Nowadays, more men tell him they’re getting a vasectomy because they don’t want their partners to have to deal with the side effects of some forms of contraception, or because their partner had to deal with childbirth and it should now be on them to contribute to family planning.

“I think part of that is the slow but perceivable shift in terms of expectations around family planning and also just the expectations of what men and women contribute to a family,” Najari said. With American institutions increasingly limiting access to abortion and contraception, those expectations will only — and rightly — grow.