It's also a good object lesson as to the folly of HSAs.

A minor but important point, particularly for the policy wonks... Ezra. HSAs are financial accounts that allow individuals to save for future qualified medical expenses on a tax-free basis. They have nothing to do with the point of your post. The plans linked to HSAs, consumer-directed health plans (CDHPs) or high deductible health plans (HDHPs), are the right things to criticize in this fashion.

That said...

The type of care that HSAs put a higher price tag on, and thus discourage, are small and discrete interactions with the health system. So they disadvantage mammograms and pap smears, but leave lumbar surgeries and angioplasties untouched. Anyone want to guess which category accounts for the majority of our health spending? Anyone want to guess which type of care studies suggest we discourage, and which type of care studies suggest we make more broadly accessible?

Its a good point, but an easy switch. Preventive medicine could actually add dollars to people's HSAs, thereby encouraging their use, and we could provide the appropriate cost-sharing for the less cost-effective procedures (or higher co-pays for less effective providers).

I've been thinking lately about an issue that I haven't seen anyone address directly. Basically, expenses like preventive care and chronic disease management are critical and in many ways more important than acute care. However, they don't actually fit that well into the basic principles of insurance, ie Pap smears and hypertension management are relatively small, recurring, predictable expenses. Insurance is better at rare, expensive, unpredictable, etc losses.

While someone clearly should pay for these expenses, because they're really important, I'm not sure insurance is the best way to do it. I guess there is a parallel with disability insurance, perhaps. I don't know, thoughts?

One might ask, why does Barack Obama hate women? From the do as I say, not as I do department:

Obama's for Equal Pay, Yet Pays Female Staffers Less Than Males
By Fred Lucas
Staff Writer
June 30, 2008

- While Democratic presidential candidate Barack Obama has vowed to make pay equity for women a top priority if elected president, an analysis of his Senate staff shows that women are outnumbered and out-paid by men.

That is in contrast to Republican presidential candidate John McCain's Senate office, where women, for the most part, out-rank and are paid more than men.

On average, women working in Obama's Senate office were paid at least $6,000 below the average man working for the Illinois senator. That's according to data calculated from the Report of the Secretary of the Senate, which covered the six-month period ending Sept. 30, 2007. Of the five people in Obama's Senate office who were paid $100,000 or more on an annual basis, only one -- Obama's administrative manager -- was a woman.

The average pay for the 33 men on Obama's staff (who earned more than $23,000, the lowest annual salary paid for non-intern employees) was $59,207. The average pay for the 31 women on Obama's staff who earned more than $23,000 per year was $48,729.91. (The average pay for all 36 male employees on Obama's staff was $55,962; and the average pay for all 31 female employees was $48,729. The report indicated that Obama had only one paid intern during the period, who was a male.)

McCain, an Arizona senator, employed a total of 69 people during the reporting period ending in the fall of 2007, but 23 of them were interns. Of his non-intern employees, 30 were women and 16 were men. After excluding interns, the average pay for the 30 women on McCain's staff was $59,104.51. The 16 non-intern males in McCain's office, by comparison, were paid an average of $56,628.83.

Interesting post. I had always assumed that men had their own routine check up requirements, but when I think about it most of the routine stuff I have to go in for is related directly or indirectly to things men don't have to deal with. Nature really gave women the raw end of the deal when it comes to physical investment and costs paid in reproduction.

I guess men, as more prone to trying to stop an SUV with their civic and other risky behavior, still pay more for certain things like car insurance but I doubt that equals out. Do men pay more for preventative healthcare later in their (post-reproductive stage) lives though I wonder?

I guess the underlying problem is as mark says, the principle of insurance doesn't really work well as a way of paying for anticipated, expected, and necessary costs. It's pretty much set up to deal with the unlikely and unexpected. So maybe, since healthcare is only occasionally an unexpected need, we ought to throw out the idea of insurance altogether as a way of paying for it. An idealistic notion right now I know, but if one were starting from scratch that would be the first thing I would do.

It is really quite simple isn't it. Women have children. The pregnancy and early care for the child, all very very expensive, falls under the mother's insurance. Thus women have more health expenses and just like obese people or smokers have higher premiums due to their higher likelihood of high costs, so do women. This isn't some great gender inequity on the part of the insurers, it is necessary based on how they work. Of course, how they work is not ideal for the health of the nation.

This was one of those Duh! posts for me. I would venture to guess that women pay more for most everything. Why do dry cleaners hate women (we pay more for the same laundering of a white shirt!), why do haircutters hate women etc? As for the pregnancy angle, I had my tubes tied after kid number 2 and when switching insurance companies, it made no difference in the premium.

It's really come to this.

Ezra you’re a dumb ass. Not just uneducated about your subject matter but a real clueless wouldn’t know how to do research if your life depended on it moron.

“So they disadvantage mammograms and pap smears”

Really is that so? Because the Federal law that made HSAs has a huge F’n exception for preventative care. In fact almost every High Deductible plan sold with an HSA covers those services at 100%. 100% means it’s free to the women, she pays nothing.

So what you’re claiming is by giving women free mammograms and pap smears insurers are some how disadvantaging them? Would you care to elaborate how the evil insurance kabala is plotting to kill off women by giving them free care?

The real question is how could you make such a stupid claim? Have you never read an HSA policy? You can look up a couple hundred online, they aren’t hard to find. How does anyone take anything you say seriously when you obviously have no idea what your talking about?

You obviously can’t grasp insurance lets see if you have any math skills;

If your insurance company pays a bill they need to charge roughly 125% of what the doctor will get paid. That means if you want insurance to pay $100 for a pap smear you need to pay $125 in premium.

Women after a certain age should get an annual pap smear.

Why would a women want to pay an additional $125 a year in premium when she could just as easily pay the $100 directly to the doctor? Please any reason will do genius, just name one that explains why that is beneficial.

Since your not able to catch one of the main and most likely largest reasons why women spend more on healthcare they are called babies. Women have them men can’t. As long as only one of the sexes can give birth there will be disparity between them. The fact you need a study to tell you this only reinforces how hopeless you are.

Why do tampon manufacturers hate women? They make them pay for those tampons once a month, and men never have to buy them. Why shouldn't they give them the tampons for free, since men don't ever have to buy any?

There is some truth in this post though. HSAs need to be allowed (encouraged) to grow to where they cover big medical expanses. The idea of HSA is to get the insured to help the insurer reduce costs.

When I was in public policy grad school, I took a policy clinic on women's health issues in LA County. It is historical... the medical profession, as we know it, has had a history of ripping out women's reproductive organs, conducting clinical trials on men while excluding women, and just treating us like second class citizens. It is no wonder that insurers rip us off for birth control pills and other commonly prescribed "women's items," while men don't have to deal with these extra expenses.

AB has a point about the tampons. Ever wonder why the big corporate toiletry companies don't use organic cotton instead of bleached and synthetic fibers? This gets to the essence of women's health in many ways.

So, because women follow standard medical advice to undergo regular exams to avoid catastrophic illnesses that would cost FAR more than routine health care, they are actually penalized by the insurance companies.

The commenter above is correct. Women are charged more for the same expenses across the board in life and studies have confirmed this. Yet they earn substantially less on the dollar. The haters on this blog can spin all they want, but numbers are numbers and truth is truth.

To top it off, the big earning medical specialties are always the ones that make money off women, i.e. fertility docs [huge rip off, very predatory, needs serious regulation], plastic surgeons, etc.

I enjoy your blog, Ezra, and our opinions overlap quite a bit. But I have an HDHP and and HSA, and think you are missing one important point: for the healthy, male or female, it's great -- I can set aside pre-tax dollars for health care and supplies that can be used long after I leave my HDHP. Preventive care and urgent/emergent care are all I need, and they are not subject to my high deductible.

It's the people who have age-related or chronic health problems that are hit with immediate and high costs every new plan year when their deductibles recycle. Sexism is an easy button to push, but please: HDHPs are hardest on the people who actually need ongoing treatment, and aren't simply following guidelines for frequent routine care.