Health Insurance gaps leave many women facing high out-of-pocket costs for reproductive care

Women frequently shoulder much higher out-of-pocket costs for essential medical treatments, particularly in reproductive health areas like fertility treatments, according to a research findings.

Research findings reveal stark disparities in health insurance coverage, leaving many women financially vulnerable and struggling to access critical care.

These gaps in coverage force many women to bear the financial burden of critical care, underscoring the need for more equitable health insurance policies.

A recent report by Deloitte analysis reveals that in the United States, women face significantly higher out-of-pocket medical costs compared to men across all age groups from 19 to 64, even when excluding pregnancy-related expenses.

The report shows that, on average, female employees with single coverage spend about $266 more per year out-of-pocket than their male counterparts—an increase of just over 18 percent—excluding costs related to pregnancy.

The analysis found that women incur higher costs not just for maternity and childbirth care, but also for a range of other services more than men including radiology, laboratory tests, mental health care, emergency services, office visits, and physical or occupational therapy.

While data on this issue is still limited in Kenya, experts suggest that the analysis reflects similar trends in the country.

On June 21, Esther* visited a hospital to consult a gynecologist due to some health issues she had been experiencing. Working in the communications industry and covered by health insurance, she was relieved to have her consultation fee of Sh2500 covered by her plan.

However, the situation took a turn when upon consultation, the gynecologist recommended a hysterosalpingogram, an X-ray procedure which helps to identify issues such as blockages or abnormalities in the fallopian tubes and uterine cavity that might be contributing to infertility.

“At the lab, I was informed that this procedure was not covered by her insurance, leaving me to pay Sh7000 out of pocket,” she adds. Things only got more complicated. Subsequent tests revealed bilateral tubal blockage, necessitating a consultation with an interventional radiologist.

“This additional visit cost me another Sh3000, out of the pocket, because apparently, the insurance does not cover for that either.” The challenges continued when the radiologist suggested a fallopian tube recanalization, a procedure estimated to cost between Sh120, 000 and Sh200,000.

Despite her efforts to negotiate with her insurance for coverage, they declined, stating that fertility treatments are not included in the plan.

Esther's situation might be related to fertility issues, which are often not covered by insurance, but studies indicate that women frequently face a greater financial burden for medical services, even with health insurance, compared to men.

Dr John Ong’ech, a medical specialist in obstetrics and gynecology, confirms this trend, expressing concern over its implications, with many women struggling to access essential reproductive health services due to financial barriers.

Mwenda Kimathi, Head of Business intelligence at Minet, an insurance risk advisory firm based in Nairobi, agrees with these sentiments,  saying that women often face specific health challenges, such as those related to menstruation, pregnancy, and hormonal issues, which may result in higher out-of-pocket expenses.

"The extent of benefits available largely depends on the insurance plan and the employer's commitment to providing comprehensive coverage for their employees," he adds. "In most cases, fertility-related issues, which are often very costly, are not covered."

According to Dr Rajesh Chaudhary, an IVF and surrogacy specialist in Nairobi, fertility treatments in Kenya can be quite expensive, with costs varying depending on the type of treatment and the clinic.

"Basic fertility consultations and initial assessments can vary in price, but more advanced treatments like in vitro fertilization (IVF) typically cost between Sh500,000 and Sh1,000,000 per cycle. Additional expenses for medications, laboratory tests, and other related services can further increase the total cost," explains Dr Chaudhary.

However, Dr. Ong’ech argues that some services are prematurely categorized as fertility treatments without first confirming whether the woman has actual fertility issues.

“For instance, treatments for conditions like fibroid, which can cause significant pain, are often not covered by insurance. Moreover, it’s only recently that some insurance providers have started covering family planning services,” he notes.

And even when it comes to fertility treatments, Dr Ong’ech argues that essential fertility treatments are critical because infertility can create significant marital difficulties.

“The lack of access to these services often puts a strain on relationships and contributes to mental health issues,” he explains.

Studies indicate that one in five women faces fertility problems, thus Dr Ong’ech believes this underscores the need for insurance companies to cover these services. “In this context, such exclusions are both unfair and discriminatory in today’s world,” he asserts.

According to Kimathi, some health providers are partly responsible for this issue, pointing out that unethical pricing practices can lead to exploitation, especially of vulnerable groups like women.

“Insurance companies typically use an index book to determine market prices, but some hospitals might not always follow these figures strictly. Instead, they might offer partial coverage for certain tests, leaving patients to cover the remaining costs out-of-pocket,” he explains.

But nonetheless, he insists that the insurance landscape requires balancing cost, coverage, and client needs. “For there to be adequate coverage and decreased out of pocket coverage, there is an urgency for insurance products to be tailored to the specific needs of different demographics,” he adds.

Dr. Ong’ech on the other hand, emphasizes that it’s time for stakeholders to review and revise policies on these issues.

“We need to consider the broader perspective, as some of these procedures can actually reduce future costs for insurance companies. For example, a family planning procedure like tubal ligation can help prevent future expenses related to cesarean sections during childbirth,” he explains.

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