Wednesday, June 18, 2008

And Walking Isn't a Medical Necessity, Either

According to Nate Jenkins at the AP, the state of Nebraska has decided that there's no need to help men who are struggling with erectile dysfunction. It already stopped Medicaid payments for Viagra and related drugs when the federal government did the same in 2006. Now it's excluding penile implants from Medicaid coverage as well.

I realize that the very term "penile implant" may have put you into a cringe. But before you close this window on your browser, consider that many men who suffer from erectile dysfunction after treatment for prostate cancer (including radiation as well as surgery) may not get much help from the drugs for erectile dysfunction. The Austin Powers vacuum pump works only for a minority. Their most effective remaining options are to try injections (yes, the needle goes where you think it does) or to undergo penile implant surgery.

These days, implants are inflatable. They're no longer a rigid rod that produces a permanent adolescent erection. The only outwardly visible sign of the implant is a fluid reservoir that apparently resembles a third testicle from close up.

From patient accounts that I've read, the erection resulting from the implant feels natural and pleasurable to both partners. Most of the men who have an implant wonder why they didn't get the surgery sooner. And while I'm not suggesting this should be anything other than a last resort, these guys sometimes brag just a little about how long they can go. Given what they've been through, I'd say they've earned bragging rights.

But apart from the cringe factor, this is what they're up against:
State Medicaid director Vivianne Chaumont said the change is consistent with a federal rule, approved in 2006, that barred the federal government from spending Medicaid dollars on erectile dysfunction drugs including Viagra. Nebraska followed suit a few months later and changed its rules to keep state Medicaid money from being spent on the drugs.

The federal government will still help pay for penile implants in states that choose to continue covering the procedure under their Medicaid plans.

“The decision was made not to cover the drugs, so it’s ... a good idea to have particular procedures for prosthesis not covered as well,” Chaumont said.

Medicaid is meant to pay for the medical necessities of needy people and “sex is not medically necessary,” she said.

(Associated Press via the Lincoln Journal-Star)
Do I even need to enumerate what's wrong with this? For one thing, it'll save small change. Jenkins reports that since 2003, a whopping three Nebraskans on Medicaid have had the surgery and the state's share for all three totaled $11,705.

The ruling is also blatantly sexist. The state Medicaid program covers breast reconstruction, as most private insurers are required to do in accordance with federal law. Where's the difference? Again, from the AP:
Chaumont, who moved to Nebraska about a year ago to take her current position, said she didn’t know why the decision was made to cover breast reconstruction under Nebraska Medicaid but added that it didn’t strike her as unreasonable.

“I don’t think breast cancer has anything to do with sexual dysfunction or sexual impotence,” she said.

Asked why it is important to cover breast reconstruction, she said that doing so “is in line with other insurers.”
I'm always uncomfortable when breast cancer and prostate cancer get pitted against each other. Both deserve adequate - no, generous - funding. It should never be a zero-sum game. And in this case, there's no conceivable reason to cover one but not the other. Breast cancer has effective advocates. Prostate cancer remains largely in the shadows. That's the only real difference.

Note also Chaumont's wholly bureaucratic justification. She has no idea why breast reconstruction is reimbursed! Maybe she implicitly sees breast reconstruction in terms of the politics of appearance and normative femininity. If you're missing a boob, you can't be a real woman. What's worse, if people have to look at your asymmetry, they might be reminded of the artificiality of the beauty ideal, the toll disease can take, and our shared mortality. Not that Chaumont is reflective enough to say any of this.

Of course, men with ED often say they no longer feel like real men. But their losses can be kept safely hidden from the public eye. Everyone else gets to pretend there's nothing wrong.

At bottom, Chaumont is enforcing the idea that sex is optional and probably downright icky or evil. That sex is not for people who are aging or ill (even if an increasing number of prostate cancer patients are in their 40s and 50s). That sex is not a part of mental health. She doesn't give a shit that their partners suffer nearly as much from the loss of marital "delight." But what gave her the right to impose her own anti-sex views on Nebraskans who've had the double bad luck to be both poor and seriously ill?

What's next? Will the state of Nebraska refuse to subsidize walkers or canes on the theory that walking is not a medical necessity? You can stay alive without walking, chewing, seeing, or fucking. And you can survive for decades without using your higher brain functions, including logic and empathy, as Chaumont's decision proves. It seems that even thinking is not a medical necessity.


Sally said...

This is absolutely about not wanting to fund something that promotes people having sex. There's just no other reasoning.

Many things aren't "medically necessary" but they're still covered. Like, when did having straight teeth, or even clean, cavity-less teeth, become a necessity?

And the only reason they feel ok about covering breast reconstruction is to make others feel comfortable around women who would otherwise be *gasp* boobless. If they have to see it, that's when they care about it.

Heather Munro Prescott said...

Given the fact that federal support for contraception has been gutted, is this any surprise?

As to Sally's comments -- there is a strong link between poor dental health and bad health overall. Tooth infections can lead to systemic ones, especially in young children and those who are immuno-compromised because of AIDS or chemotherapy. Medicaid does cover dental treatment but the majority of dentists won't accept medicaid patients. They would rather make loads of money on purely cosmetic procedures.

Sungold said...

Sally and Heather -

It's absolutely right that this is all part of a broad anti-sex agenda. We tend to think of it as manifesting in sexist restrictions on delivery of services to women, as in your example of contraception, Heather, but anti-sex policy can also be remarkably gender-blind. This is not what I mean when I say I want a less gender-bound society!

Dental infections can also lead to pregnancy complications, including miscarriage. I didn't realize that dentists were turning Medicaid patients away, but it shouldn't surprise me, either. In SE Ohio, many (most?) dermatologists won't accept my university's otherwise decent insurance plan. Again, I guess they make enough from cosmetic stuff that practicing regular medicine within managed-care guidelines is unattractive.

Sally said...

Okay, bad example with the teeth, but you understand what I'm saying! It was just the first thing that came to my mind. I'm just saying that there are things that are covered that aren't a medical necessity so using that as the excuse is crap.

Sungold said...

Yeah, Sally. The underlying principle is that if it won't kill you (and soon!) it's not medically necessary. It's one way to save money big time (and not just the peanuts that this Nebraska decision will save the state) but the human costs are incalculable.