A “viewpoint” article published in JAMA this week (authored by March C. Politi, Adam Sonfield, and Tessa Madden) briefly summarizes how the Affordable Act Act (ACA) expands access to contraception, but also describes the various “challenges” that thus far have prevented the full implementation of this provision.

To my mind, the points they make demonstrate how the underlying, structural flaws of our health care system make even relatively straightforward and useful reforms like the ACA’s contraception mandate enormously difficult and complex to realize in practice.

As they briefly summarize in the article (“Addressing Challenges to Implementation of the Contraceptive Coverage Guarantee of the Affordable Care Act”), the ACA includes a provision that mandated that contraception-related health care – including medications, devices, services (including sterilization), office visits, and education – be covered by privates insurers without “cost sharing” (i.e. copayments or deductibles).

This is unquestionably a good and useful measure: contraception-related care is a fundamental component of comprehensive reproductive health care. There is no plausible reason to punish women who use contraception by imposing out-of-pocket payments at the time of use (the same could be said of all medically-necessary health care, in my opinion, but that’s a story for another time).

The article then briefly summarizes the various games insurers have played in preventing the implementation of this rather straightforward provision.  For instance, they note that some insurers have left out coverage for certain modes of contraception (though they assert that this should be addressed by new federal rules), and also that insurers have not been reliably covering contraception-related clinical care.  “Inappropriate insurance practices,” they write, “may therefore lead to patients being erroneously charged for services that should be covered with no out-of-pocket costs, potentially interfering with patients’ ability to practice contraception consistently and effectively.”

But it is when they turn to the issue of billing and coding that the ridiculous complexity of our health care system – and the harm that this complexity causes – becomes most evident.  As a result of the vagaries of billing codes, what is theoretically fully covered may not be in practice.  As they write:

Physicians, other clinicians, and health care organizations may find it difficult to appropriately bill for contraceptive services in a way that ensures that patients are properly exempt from cost sharing. If a patient receives contraceptive counseling as part of a well-woman examination, the situation is straightforward because the well-woman examination has a specific Current Procedural Terminology code and is considered a covered preventive service. However, if a patient has an office visit solely for contraceptive counseling (which does not have a specific billing code), the clinician or health care center must bill an appropriate evaluation and management code (which can be used for many purposes) and billing modifier (ie, 33) to specify that the visit was for the preventive service, contraceptive counseling. Many clinicians and health organizations are unaware of this modifier, and some insurers have been slow to program their billing systems so that this modifier automatically triggers the patient’s exemption from cost sharing when the included diagnosis codes (formerly International Classification of Diseases, Ninth Revision [ICD-9], now ICD-10) indicate that primarily preventive services were provided.

Of course, it is ultimately women who are penalized by this byzantine structure of coding.

But the complexities don’t end there.  As they describe:

This is of course ridiculous.  In reality, office visits can be a combination of things, and attempts to classify them as purely “preventive” or not is a fiction.  It’s also entirely unnecessary: if office visits for both “preventive” care and “non-preventive” both didn’t have cost sharing, none of this would matter (at least from the patient’s perspective).

They finally note that none of these protections are available for women who obtain contraception-related services “out-of-network.”  Yet this may happen unwillingly: as they describe, a women may undergo a sterilization procedure at a facility that’s inside of the insurance network, but the anesthesiologist involved in the case may be out-of-network.

The story of the contraception coverage mandate of the ACA thereby speaks to the enormous difficulty of effectively – much less efficiently! – moving towards universal health care within a structure dominated by private insurers.